PMR or GCA Patient Questionnaire Question Title * 1. Name: (Required.) Question Title * 2. Please indicate the age range you fall into. 18-30 31-40 41-50 51-60 61 and older Question Title * 3. Do you reside in the US? Yes No Question Title * 4. If you reside in the US, please list your city/state. Question Title * 5. If you do not reside in the US, please list your city/province & country. Question Title * 6. Have you been diagnosed with polymyalgia rheumatica (PMR)? (Required.) Yes No Question Title * 7. If yes, when were you diagnosed with polymyalgia rheumatica (PMR)? (month and year) Question Title * 8. Have you been diagnosed with giant cell arteritis (GCA)? (Required.) Yes No Question Title * 9. If yes, when were you diagnosed with giant cell arteritis (GCA)? (month and year) Question Title * 10. Would you be interested in sharing your experience living with PMR or GCA? Please select all that apply. Focus Group or Advisory Council (if VF-led) Focus Group or Advisory Council (if 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 PMR or GCA? 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 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!
