Questionnaire about Psoriasis

Questionnaire about Psoriasis

Please answer a few questions so that we can better understand your situation.**

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Your name:		Patient Name (if different)
Your Email Address:
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Sex: Female Male	Age:
Race:	Weight: (pounds)
How many years ago when your psoriasis was diagnosed? No Answer Less than 1 year 1 to 5 years 6 to 10 years 10 to 20 years over 20 years	Which part of your body does the psoriasis affect? Face Scalp Arm Leg Hand Foot Body Nail
Do you know any family member who is diagnosed of psoriasis? No Answer Yes No	Were you diagnosed of psoriatic arthritis? No Answer Yes No
What type of Psoriasis do you think you might have? No Answer plaque guttate pustular inverse erythrodermic	What type of treatment have you used before? Topical UVB or PUVA Oral antipsoriatic medication Other
Have you tried any alternative treatment? No Answer Yes if Yes, what kind? No	How serious is your psoriasis? No Answer Mild (< 2% skin) Moderate (< 10% skin) Severe
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**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.