EUSTAR/FESCA
Scleroderma survey
43%
Exit Survey
Demographics
Part 1
1.1) Can you confirm that you are affected by systemic sclerosis (systemic sclerosis (SSc) or scleroderma) ?
Yes
No
Unsure
1.2) What type of scleroderma do you have? (if necessary ask your physician)
Diffuse cutaneous
Limited cutaneous
Sine scleroderma
Undefined
1.3) What are the results of your immunological tests ? Please, click on the positive tests (if necessary ask your physician).
Anti-nuclear antibodies
Anti-centromere antibodies
Anti-topoisomerase antibodies
Anti-RNA polymerase III antibodies
1.4) How old are you and what is your disease duration in years since the first symptoms of your disease ?
1.4.1) Age in years at the time of fulfilling this survey:
1.4.2) Duration of symptoms including Raynaud (years)
1.4.3) Duration of non-Raynaud's symptoms (skin, joints...) (years):
1.5.1) Are you member of a national patient association ?
Yes
No
1.5.2) In which country are you living?
Armenia /ARM
Australia /AUS
Belarus /BLR
Belgium /BEL
Brazil /BRA
British Virgin Islands /IVB
Bulgaria /BUL
Canada /CAN
Chile /CHI
China (People’s Republic of) /CHN
Colombia /COL
Costa Rica /CRC
Croatia /CRO
Cuba /CUB
Denmark /DEN
Dominican Republic /DOM
East Africa
England /ENG
Estonia /EST
Finland /FIN
France /FRA
Georgia /GEO
Germany /GER
Great Britain /GBR
Greece /GRE
Guyana /GUY
Haiti /HAI
Hong Kong, China HKG
Hungary /HUN
India /IND
Indonesia /INA
Ireland /IRL
Israel /ISR
Italy /ITA
Japan /JPN
Kingdom of Saudi Arabia /KSA
Korea /KOR
Kosovo /KOS
Lithuania /LTU
Luxembourg /LUX
Madagascar /MAD
Maldives/ MDV
Mexico /MEX
Monaco /MON
New Zealand /NZL
Netherlands
North Africa
Peru /PER
Philippines /PHI
Poland /POL
Portugal /POR
Romania /ROM
Russian Federation /RUS
Serbia /SRB
Saudi Arabia /KSA
Scotland
South Africa /RSA
Spain /ESP
Sub-Saharan Africa
Switzerland /SUI
Tahiti /TAH
Thailand /THA
Turkey /TUR
Ukraine /UKR
United Arab Emirates /UAE
United States of America /USA
Uruguay /URU
Venezuela /VEN
Vietnam /VIE
Wales
West Africa
Other
1.6.1) Please rank from 0 to 10 (0 = not at all severe & 10 = most severe) the impact on your daily life of the following organ system :
0
1
2
3
4
5
6
7
8
9
10
Lung
Heart
Raynaud phenomenon
Digital ulcers
Gastro-intestinal (including ano-rectal)
Musculo-skeletal
Kidney
Skin
Other
1.6.2) If there's another organ system not mentioned in the above list, please specify in the field below:
1.7.1) Please, rank from 0 to 10 (0 = not at all severe & 10 = most severe) the organ system involvements that you seems the most severe and the most serious on your illness :
0
1
2
3
4
5
6
7
8
9
10
Lung
Heart
Raynaud phenomenon
Digital ulcers
Gastro-intestinal (including ano-rectal)
Musculo-skeletal
Kidney
Skin
Other
1.7.2) If there's another organ system not mentioned in the above list, please specify in the field below.
1.8.1) Have you been exposed to tobacco?
Never
Passive smoking e.g. lived with a smoker
Former smoker
1.8.2) Did you stop smoking after you got scleroderma?
Yes
No
1.8.3) Are you a currently a smoker?
Yes
No
Years of smoking
Average cig/day
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