Lupus (MR)

Welcome to Our Qualifying Questionnaire

We are a branch of a larger market research company, whose goal is to make contact with as many people diagnosed or involved in the treatment of Lupus. We will be looking to reach out to those interested in the form of online surveys and telephone discussions to help understand the needs of Lupus patients and caregivers. When contacted and qualified we will pay respondents for their time (up to $100).

This project is solely concerned with marketing research and there will be no attempts to sell you anything or influence your pharmaceutical or treatment options in any way.

All information collected during the surveys or phone discussions will be completely confidential in that we will not show your name or any other identifying information to our clients.

Question Title

* 1. Are you the diagnosed patient or caregiver of diagnosed patient?

Patient

Caregiver

Question Title

* 2. When Diagnosed?

Question Title

* 3. Note Treatment use ever/currently

	Ever	Current
NSAIDs (Advil, Motrin, others) and naproxen (Aleve)	NSAIDs (Advil, Motrin, others) and naproxen (Aleve) Ever	NSAIDs (Advil, Motrin, others) and naproxen (Aleve) Current
Steroids, Corticosteroid medication, such as prednisone	Steroids, Corticosteroid medication, such as prednisone Ever	Steroids, Corticosteroid medication, such as prednisone Current
Antimalarial drugs (hydroxychloroquine (Plaquenil))	Antimalarial drugs (hydroxychloroquine (Plaquenil)) Ever	Antimalarial drugs (hydroxychloroquine (Plaquenil)) Current
belimumab (Benlysta)	belimumab (Benlysta) Ever	belimumab (Benlysta) Current
Immunosuppressants (Imuran, Gengraf, etc)	Immunosuppressants (Imuran, Gengraf, etc) Ever	Immunosuppressants (Imuran, Gengraf, etc) Current

Other (please specify)

Question Title

* 4. Please provide contact information as noted. Name and phone # not required at this time.

Name:

ZIP: *

Country: *

Email Address: *

Phone Number:

Thank you very much for taking the time to fill out this short questionnaire. We are collecting basic information to match individuals with specific survey requirements in order to invite your participation.