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Please tell us |
| Your e-mail address (required): |
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1. Your date of birth: (month/date/year): |
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| 2. Your gender: |
Male
Female |
| 3, Year of diagnosis: |
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Please check off yes or no to the following questions. Please be reminded your answers will be kept completely anonymous. |
4. I have not been diagnosed with systemic sclerosis or limited cutaneous scleroderma (if you have scleroderma, check no:
Yes
No
If yes, check which one:
Systemic Sclerosis
Limited Cutaneous Scleroderma
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| 5. I am not able to read, write, and speak English fluently. |
Yes
No |
| 6. I have another major chronic disease other than scleroderma: (i.e. cancer, heart disease, respiratory diseases) |
Yes
No
Other |
| 7. I have a history of substance abuse: |
Yes
No |
| 8. I have been diagnosed with a major psychiatric illness: (i.e. major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder) |
Yes
No |
| 9. I have dementia and other conditions which would influence my ability to answer. |
Yes
No |
| 10. I am UNDER the age of 18. |
Yes
No |
We appreciate your time in filling out the information above. Unfortunately, if you checked "yes" to any of the previous questions, you should not proceed to take the rest of the survey. Please close this window.
If you did NOT check yes to any of the previous questions, hit submit and continue with survey.
Thank you. |
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