Survey - My Scleroderma Story - Scleroderma Foundation

My Scleroderma Story

Telling your story can be difficult. Where to start? What to say?
This questionnaire can help. A few words can make a big impact to a wide audience. Don't want to answer a question? Leave it blank. Don't worry if you don't think you write well. Just write what you feel.

Please provide your information:

If you have previously registered, please to prepopulate your information.

Name:

First Required	Last Required

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

Phone Number: Required

Gender: Required

Date of Birth: Required

Date of Birth:

If you respond and have not already registered, you will receive periodic updates and communications from Scleroderma Foundation.

Yes, I would like to receive postal mail from Scleroderma Foundation

Question - Not Required - Age:

Question - Not Required - Parents first and last name (if younger than 18):

Question - Required - May we use your story in our marketing and outreach efforts?

Question - Required - Do you have scleroderma? Yes, I have systemic scleroderma (systemic sclerosis; SSc)
Yes, I have localized scleroderma (morphea)
Yes, I have linear scleroderma
Yes, I have en coup de sabre
No, I do not have scleroderma

Question - Not Required - If you have scleroderma, please tell us the year and month of the diagnosis, to the best of your recollection.

Question - Not Required - I want everyone to know that I am...

Question - Not Required - Even though I have scleroderma, I'm still...

Question - Not Required - People are wrong when they assume...

Question - Not Required - But people are right to think...

Question - Not Required - Scleroderma's biggest impact on my life is...

Question - Not Required - Scleroderma has taken away...

Question - Not Required - Scleroderma has given me...

Question - Not Required - My greatest wish is that...

Question - Not Required - One thing people can do to make life better for people with scleroderma is...

Disclaimer | Privacy | Disclosures | Share

The Scleroderma Foundation is a qualified national nonprofit operating under 501(c)(3) status. The foundation’s federal tax identification number is 52-1375827. Our primary goal is to raise funds for our three-fold mission of support, education and research. The foundation has 20 active chapters and 160 support groups across the country.