Psoriasis Survey - A3

In order to determine if you may qualify for a research study of an investigational medication for psoriasis, we will ask you a few questions about your experience with psoriasis and what medications you have tried. We need to know this information to help determine if you may be eligible to participate in the study. You may stop answering at any time and do not need to answer any questions that make you feel uncomfortable. All information you provide will be kept confidential. Please feel free to call us for more information at (619) 512-3376.

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* 1. Please tell us about yourself.

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 2. What gender are you?

Male

Female

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* 3. Are you between 18 - 75 years old?

Yes

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* 4. If female, are you pregnant, nursing, or planning a pregnancy?

Yes