Psoriasis questionnaire

Horizons Clinical Research Center, LLC

Questionnaire

Questionnaire for potential volunteers interested in participating in the research study for the

treatment of

moderate to severe

psoriasis.

You are under no obligation to answer any of the following questions; however, as part of our pre-screening

process it will be very helpful if you do. Any information that you give will remain confidential and will not be shared

with anyone without your permission or except by law.

How did you learn about us?

Are you at least 18 years of age?

Yes

Do you have moderate to severe plaque psoriasis?

Yes

Does the psoriasis affect 5% to 20% of your body?

Yes

Are you pregnant, planning to become pregnant, or breastfeeding?

Yes

Would you like us to contact you for future psoriasis studies?

Yes

Your name:

Your e-mail address:

Your phone number:

Comments:

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