38%
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