1.
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+?
2.
Leukemia is a type of cancer that affects blood and bone marrow. Are you or a loved one living with any of the following forms of Leukemia?
Are you treating your leukemia? Common treatments for leukemia are as follows: chemotherapy, targeted therapy, radiation therapy, and others.
3.
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?
4.
Have you or someone you care for been diagnosed with Epilepsy (Epilepsy is a seizure disorder that can affect anyone)?
Do you have/take rescue medication in the event of a seizure?
How do you administer the rescue medication?
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.)
5.
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)
6.
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?
7.
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?
8.
Are you or someone close to you one of the millions of Americans living with Hepatitis C (Hep C)?
9.
Have you or someone in your family been diagnosed with Hereditary Angioedema (HAE), a rare condition characterized by recurring episodes of severe swelling?
10.
Do you or a loved one suffer from any respiratory conditions that affect your/their breathing?
What are the respiratory conditions? (choose all that apply)
Do you or a loved one treat severe asthma with a prescription medication?
Is the person with Asthma under 18 years old?
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