Sarcoidosis Research Survey
 
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Thank you for participating in the Sarcoidosis Online Sites Research Survey.

We hope the information we collect will lead to better medications, treatment and ultimately the cause and cure for sarcoidosis.

The more accurate the information you provide the more likely it will help those with sarcoidosis.

Please Note:  All of your information on this questionnaire will be held in the strictest of confidence. It is not mandatory to answer any question with which you do not feel comfortable. The only exception is your name and email address. These are needed to prevent duplicate entries and attempts by some (we have no idea why) to skew the results. We do not share personally identifiable information (e-mail addresses, names) with third parties.

  1. Your Name: *required   
     
  2. Email Address: *required   
    example: YourScreenName@provider.com
     
  3. Sex: Female  Male 
     
  4. Ethnicity: (Check all that apply): African American Asian Caucasian European
    Hispanic Native American   Other:
     
  5. Have you been diagnosed with sarcoidosis? Yes  No
     
  6. Current Age:    Age at diagnosis sarcoid?
     
  7. Was your diagnosis confirmed by a biopsy? Yes  No
     
  8. Briefly, what were your symptoms at the time of diagnosis?

     
  9. What types of sarcoidosis have you been diagnosed with? (Check all that apply)
    Pulmonary (Lung)  Cardiac (Heart)  Cuteaneous (Skin)  Osseous (Bone, Bone Marrow)
    Mediastinal (Lymph Nodes)  Neurological (Brain, Spinal Cord, CNS Central Nervous System)
    Ocular (Eyes)   Other:
     
  10. What is or was your occupation?:
     
  11. Treatments that you have received:
    Corticosteroid  Methotrexate  Chemotherapy  Organ Transplant
    Other:

     
  12. What is the specialty of the doctor(s) currently managing your sarcoid?
    Family Practice   Internal Medicine   Pulmonologist   Rheumotologist
    Other:

     
  13. How would you classify your current sarcoid condition?
    In Remission  Stable   Periodic flare ups   Progressively worsening
     
  14. During flare ups, what symptoms have you noticed:
    Cough  Skin rash  Fatigue  Heel/foot pain  Others:
     
  15. Do you have pain related with your Sarcoid? Yes  No
     
  16. Where is the majority of pain you experience? (Check all that apply)
    Chest  Back  Left sided chest  Right sided chest  Joints  Head
    Topical (skin) Eyes  Other:
     
  17. What other diseases have you had?
    Chicken pox    Measles   Mumps   Shingles G6PD blood deficiency
    Other diseases?:

     
  18. Any other Comments: This is the place for anything that might help us find a cure for sarcoidosis.
    Or share your comments or stories here: Sarcoidosis Online Sites Message Forum

   19.) *Finally, spell out how many letters there are in the word Sarcoidosis.
     
*required  (use all lower case letters)

 

Thank you for taking the time to fill out the Sarcoidosis Online Sites Research Survey.

 

*Why question 19? It helps us control fraudulent survey postings. Thanks for your help!

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