SJS Survey






























Patients Name: *
Completing form on behalf of patient:

Yes    
No
Address:

City:

State:

Zip:

E-Mail Address: *
Phone Number:

What is your gender?:

Male,    
Female
Ethnic background:

(Optional)
Did patient survive?:

Yes    
No
Did you have Stevens Johnson Syndrome?:

Yes,    
No
Did you have Toxic Epidermal Necrolysis?:


Yes,     
No
When did you have SJS/TEN?:

(Please list month and year)

Month:
, Year:
What was your age when you had your SJS/TEN?:
Was your SJS/TEN from a drug, and if so please
list the name?:
Were you hospitalized and if so for how
long?:
What hospital were you hospitalized in?:

(This will assist us in helping future patients with names of facilities that
have experience in treating SJS).
What type of treatment did you receive?:

(check all that apply).

IVIG,   
Steroids,   
Supportive care,
Intubation,   
Ocular,   
N/A
  
Was your case of SJS/TEN reported to the FDA by
your physician OR you?: *

(Please, help us by reporting to FDA [ Click here ].)
Yes,
     No
Would you be interested in being contacted by
the media for an interview?:

Yes,
     No
Would you be interested in participating in any
SJS research study programs?:

Yes,
     No
Please list complications you have experienced
as a direct result of SJS:

(i, e,: dry eye syndrome, blindness, asthma?)
Would you like be contacted by other SJS
patients in your area?: *

Yes,    No
I choose to share my information with other SJS
patients: *

Yes,    
No





Field marked with * are required..!