{"id":588,"date":"2012-07-26T17:42:43","date_gmt":"2012-07-26T17:42:43","guid":{"rendered":"http:\/\/www.annetaylorfarrell.com\/?page_id=588"},"modified":"2012-07-26T17:42:43","modified_gmt":"2012-07-26T17:42:43","slug":"sjs-survey","status":"publish","type":"page","link":"https:\/\/sjsupport.org\/?page_id=588","title":{"rendered":"SJS Survey"},"content":{"rendered":"

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Patients Name: *<\/font><\/b>

\n<\/td>\n<\/tr>\n

Completing form on behalf of patient: <\/b>

\n\t\tYes<\/input>    
\n\t\tNo<\/input><\/p>\n
\n\t\t\tYour name: \n\t\t<\/div>\n<\/td>\n<\/tr>\n

Address: <\/b>

\n<\/td>\n<\/tr>\n

City: <\/b>

\n<\/td>\n<\/tr>\n

State: <\/b>

\n<\/td>\n<\/tr>\n

Zip: <\/b>

\n<\/td>\n<\/tr>\n

E-Mail Address: *<\/font><\/b>
\n

\n<\/td>\n<\/tr>\n

Phone Number: <\/b>

\n<\/td>\n<\/tr>\n

What is your gender?:<\/b>

\nMale,    
\nFemale <\/td>\n<\/tr>\n

Ethnic background:<\/b>

\n(Optional)

\n
\n
Did patient survive?: <\/b>

\n\t\tYes<\/input>    
\n\t\tNo<\/input><\/p>\n
\n\t\t\tIf patient is deceased date of death?: \n\t\t<\/div>\n<\/td>\n<\/tr>\n

Did you have Stevens Johnson Syndrome?:<\/b>

\nYes,    
\nNo <\/td>\n<\/tr>\n

Did you have Toxic Epidermal Necrolysis?:<\/b>
\n

\nYes,     
\nNo <\/td>\n<\/tr>\n

When did you have SJS\/TEN?:<\/b>

\n(Please list month and year)

\nMonth: <\/td>\n<\/tr>\n

What was your age when you had your SJS\/TEN?:<\/b>

\n<\/td>\n<\/tr>\n

Was your SJS\/TEN from a drug, and if so please
\nlist the name?:<\/b>

\n<\/td>\n<\/tr>\n

Were you hospitalized and if so for how
\nlong?:<\/b>

\n<\/td>\n<\/tr>\n

What hospital were you hospitalized in?:<\/b>

\n(This will assist us in helping future patients with names of facilities that
\nhave experience in treating SJS).

\n<\/td>\n<\/tr>\n

What type of treatment did you receive?:<\/b>

\n(check all that apply).

\n IVIG,   
\n Steroids,   
\n Supportive care,
\n Intubation,   
\n Ocular,   
\n N\/A
  
\n\n<\/td>\n<\/tr>\n

Was your case of SJS\/TEN reported to the FDA by
\nyour physician OR you?: *<\/font><\/b>

\n(Please, help us by reporting to FDA [ Click here<\/a> ].)
\nYes,
\n     No\n<\/td>\n<\/tr>\n

Would you be interested in being contacted by
\nthe media for an interview?:<\/b>

\nYes,
\n     No <\/td>\n<\/tr>\n

Would you be interested in participating in any
\nSJS research study programs?:<\/b>

\nYes,
\n     No <\/td>\n<\/tr>\n

Please list complications you have experienced
\nas a direct result of SJS:<\/b>

\n(i, e,: dry eye syndrome, blindness, asthma?)

\n<\/td>\n<\/tr>\n

Would you like be contacted by other SJS
\npatients in your area?: *<\/font><\/b>

\nYes,    No <\/td>\n<\/tr>\n

I choose to share my information with other SJS
\npatients: *<\/font><\/b>

\nYes,    
\nNo <\/td>\n<\/tr>\n<\/table>\n<\/td>\n<\/tr>\n


\n

\n\n<\/td>\n<\/tr>\n
\n

Field marked with *<\/b><\/font> are required..!<\/td>\n<\/tr>\n<\/table>\n


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\n<\/p>\n

<\/p>\n<\/form>\n","protected":false},"excerpt":{"rendered":"

Patients Name: * Completing form on behalf of patient: Yes     No Your name: Address: City: State: Zip: E-Mail Address: * Phone Number: What is your gender?: Male,     Female Ethnic background: (Optional) Select One… WhiteBlack HispanicAsian\/Pacific IslanderAmerican Indian\/Alaskan Native Other Did patient survive?: Yes     No If patient is deceased date of death?: 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: Choose one…JanuaryFebruary MarchApril MayJuneJulyAugustSeptemberOctober NovemberDecember , 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..!<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-588","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/sjsupport.org\/index.php?rest_route=\/wp\/v2\/pages\/588","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sjsupport.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sjsupport.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sjsupport.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/sjsupport.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=588"}],"version-history":[{"count":0,"href":"https:\/\/sjsupport.org\/index.php?rest_route=\/wp\/v2\/pages\/588\/revisions"}],"wp:attachment":[{"href":"https:\/\/sjsupport.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=588"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}