JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Share your story
This short survey will help us better understand how psoriasis and/or eczema has impacted you. The more we understand our patients, the better we can be. We would love to hear from you.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
What is your age?
*
<20
20 - 29
30 - 39
40 - 49
50 - 59
60+
Other:
What is your gender?
*
Male
Female
Non-Binary
Prefer not to say
Other:
What is your ethnicity?
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Other:
Which U.S. state do you live in?
*
Your answer
How severe is your psoriasis and/or eczema?
*
None
Mild
Moderate
Severe
Other:
Where on your body is your skin affected?
*
Feet
Legs
Pelvis
Stomach
Chest
Arms
Back
Neck
Face
Scalp
Other:
Required
How many years have you had psoriasis and/or eczema?
*
N/A
<1 years
1 - 5 years
6 - 10 years
10+ years
Other:
What treatments have you already tried?
Corticosteroids
Vitamin D analogues
Retinoids
Coal Tar
Sunlight
UVB Light (Narrowband/Broadband)
Psoralen plus ultraviolet A (PUVA)
Methotrexate
Biologics (e.g. Humira, Enbrel, Taltz, etc.)
Other:
What has been your experience with these treatments? Please share your story.
Your answer
How important is it to you to find an effective treatment for your psoriasis?
*
Not that important
1
2
3
4
5
Very important
After reviewing the Solay site, what features of the therapy were most interesting to you?
Your answer
Did you have any questions about this therapy that the site did not answer?
Your answer
Any other thoughts/feedback to share?
Your answer
Can we reach out and contact you? If so, please provide your email.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
