Behçet's Patient Questionnaire Question Title * 1. Name: Question Title * 2. Please indicate the age range you fall into. under 18 18-30 31-40 41-50 51-60 61 and older Question Title * 3. How would you describe your race/ethnicity? (Select all that apply) American Indian or Alaska Native Asian or Asian American Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or other Pacific Islander White Another race Question Title * 4. Do you reside in the US? Yes No Question Title * 5. If you don't live in the US, which country do you reside in? Question Title * 6. Please list your city/province you reside in. Question Title * 7. Have you been diagnosed with Behçet's disease? Yes No Question Title * 8. If yes, when were you diagnosed with Behçet's disease? (month and year) Question Title * 9. Which of the following organs or body systems have been affected by your Behçet's disease? (Please select all that apply) Mouth (e.g., oral ulcers) Skin (e.g., skin lesions, rashes) Eyes (e.g., uvettis, retinal inflammation) Genitals (e.g., genital ulcers) Kidneys (e.g., inflammation, protein in urine, kidney stones) Brain and nervous system (e.g., neurological symptoms) Other (please specify) None of the above Question Title * 10. Would you be interested in sharing your experience living with Behçet's disease? Please select all that apply. Focus Group or Advisory Council (if VF-led) Focus Group or Advisory Council (if industry-led) Participate in formal or informal in-depth interviews (industry-led) Sharing your story to be used for social media via blog story or video (if VF-led) Sharing your story to be used for social media via blog story or video (if industry-led) Sharing your story at an in-person event (if VF-led) Sharing your story at an in-person event (if industry-led) None of the above Question Title * 11. If you selected an industry-led selection above, do you grant the VF permission to share your contact information should they seek to connect with patients living with Behçet's disease? Yes No Not Applicable Question Title * 12. Please check all activity boxes that apply to you: I have participated in a clinical trial or study In the past, I have participated in a patient focus group or been part of a patient advisory council I have a healthcare background None of the above apply to me Question Title * 13. Phone Number: Question Title * 14. Email Address: Thank You!
