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1.	Have you or someone you care for been diagnosed with Cancer?

	Yes, I have been diagnosed
	Yes, someone I care for has been diagnosed
	No

What type of Cancer has been diagnosed?

	Advanced Bladder Cancer
	Bladder Cancer
	Breast Cancer
	Cervical Cancer
	Colorectal (Colon) Cancer
	Gastric Cancer
	Head/Neck Cancer (including mouth, throat, or voice box)

	Kidney Cancer
	Leukemia
	Liver Cancer
	Non-small Cell Lung Cancer (NSCLC, more common)
	Small Cell Lung Cancer (SCLC, less common)
	Non-Hodgkin Lymphoma

	Ovarian Cancer
	Pancreatic Cancer
	Prostate Cancer
	Skin Cancer
	Thyroid Cancer (Differentiated, Medullary, or Anaplastic)
	Other Cancer not listed above

Is the cancer spreading (metastatic) or is there concern it will spread?

Yes

No

Do you have late stage lung cancer?

Yes

No

Have you or a loved one have had a blood test that was EGFR+?

	Yes
	No
	Don't know

2.	Do you or someone close to you have Psoriasis?

	Yes, I do
	Yes, someone close to me
	No

How would you describe the severity of the Psoriasis?

	Mild
	Moderate
	Severe

Please tell us what medications have been used in the last year to treat the Psoriasis: (choose all that apply)

	Over-the-counter Creams or Ointments
	Prescription Creams
	Prescription Pills

	Injections
	None of these

3.	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?

	Yes, I am
	Yes, a family member
	No

Which do you/they have?

	Crohn�s Disease
	Ulcerative Colitis

Which medication are you or your loved one taking to treat the condition?

	ENTYVIO^� (vedolizumab) - Click here for Prescribing Information
	HUMIRA^� (adalimumab)
	REMICADE^� (infliximab)
	RINVOQ^� (upadacitinib)

	STELARA^� (ustekinumab)
	Other
	Not on medication

4.	Have you or someone you care for been diagnosed with Epilepsy (Epilepsy is a seizure disorder that can affect anyone)?

	Yes, myself
	Yes, an adult I care for aged 18+
	Yes, a child under 18
	No

Do you have/take rescue medication in the event of a seizure?

Yes

No

How do you administer the rescue medication?

	Oral Pill
	Dissolve Under Tongue

	Nasal Spray
	Rectal Gel

Does the person with Epilepsy experience seizure clusters? (Seizure clusters are periods of increased seizure activity, which is having two or more seizures in a 24-hour period.)

Yes

No

5.	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.

Yes

No

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?

Yes

No

7.	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?

	Yes, GERD
	Yes, EOE
	Yes, both GERD and EOE
	No

8.

Have you or someone you care for been diagnosed with Huntington�s Disease?
Typical symptoms of Huntington�s disease include:

difficulty concentrating and memory lapses
stumbling and clumsiness
involuntary jerking or fidgety movements of the limbs and body
mood swings and personality changes
problems swallowing, speaking and breathing
changes in balance and coordination

	Yes, myself
	Yes, someone I care for
	No

Have you or someone you care for been experiencing symptoms of Chorea (brief, abrupt, irregular, unpredictable, non-stereotyped movements)?

Yes

No

9.	Are you or someone you care for diagnosed with Atrial Fibrillation, or AFib?

	Yes, I have
	Yes, a loved one has
	No

Which medication are you or your loved one taking to treat the condition?

	Eliquis^� (apixaban)
	Pradaxa^� (dabigatran)
	XARELTO^® (rivaroxaban) - Click here for Prescribing Information

	Lovenox^® (enoxaparin sodium)
	None of the above

10.	Do you or someone you care for have Type 2 Diabetes?

	Yes, myself
	Yes, someone I care for
	No

Has your loved one experienced a condition known as Diabetic Macular Edema (DME) that affects your eyes/vision?

Yes

No

Is the person with diabetes using a Glucose Monitor?

Yes

No

Have you experienced a condition known as Diabetic Macular Edema (DME) that affects your eyes/vision?

Yes

No

Is the person with diabetes living with any of the following diabetes-related health conditions? (Choose all that apply)

	Heart Disease / Cardiac Conditions
	Hypothyroidism (Under-active Thyroid resulting in weight gain)
	Kidney Disease / Chronic Kidney Disease

	Other
	None of These


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