1.
Do you or someone close to you have Psoriasis?
How would you describe the severity of the Psoriasis?
Please tell us what medications have been used in the last year to treat the Psoriasis: (choose all that apply)
2.
Have you or someone you care for been diagnosed with Cancer?
What type of Cancer has been diagnosed?
Is the cancer spreading (metastatic) or is there concern it will spread?
Do you have late stage lung cancer?
Have you or a loved one have had a blood test that was EGFR+?
3.
Do you or someone close to you occasionally experience uncontrolled or involuntary movements like facial tics, movements around the mouth or rapid eye blinking? This could be a condition called Tardive Dyskinesia (TD) and can result from prolonged use of certain medications.
4.
Are you or a family member living with Crohn’s Disease (CD) or Ulcerative Colitis (UC), commonly referred to as Inflammatory Bowel Disease or IBD?
Which medication are you or your loved one taking to treat the condition?
5.
Have you or someone you care for been diagnosed with either IgAN (immunoglobulin A nephropathy) or complement 3 glomerulopathy (C3G)? The most common symptoms include the following:
Blood in your urine that can make it appear dark brown or cola colored
Foamy urine
Pain in one or both sides of your back below your ribs
High blood pressure
High cholesterol
Swelling (edema) in your hands and feet
6.
Have you or someone you care for been diagnosed with a sleep disorder characterized by excessive daytime sleepiness and/or sudden attacks of sleep?
Do you struggle with your CPAP machine?
7.
Under-active thyroid (Hypothyroidism) is a common condition mostly affecting women. Symptoms can include unexplained weight gain, cold sensitivity and fatigue . Do you or someone close to you have Hypothyroidism?
8.
Are you or someone you care for diagnosed with Atrial Fibrillation, or AFib?
Which medication are you or your loved one taking to treat the condition?
9.
Have you or has someone you care for been diagnosed with Parkinson’s Disease and is experiencing, or has experienced off-time while medicated?*
Have you or someone you care for had Parkinson's for 5 or more years?
10.
Gastroesophageal Reflux Disease (GERD) and Eosinophilic Esophagitis (EOE) are different conditions with similar symptoms; heartburn/regurgitation, abdominal or chest pain and difficulty swallowing. Have you or a loved one been diagnosed with GERD or EOE?
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