Invitation to Participate in a Scleroderma Survey

You are being asked to participate in a research study being conducted by the Medical University of South Carolina on the role of environmental factors in the development of systemic sclerosis/scleroderma. To participate in this research study, please complete the survey below. Thank you.

First Name

Last Name

Age (years)

Date of birth

* must provide value

M-D-Y

Gender

Female

Male

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Race

Ethnicity

What is your current phone number?

* must provide value

What is your current e-mail address?

What is your disease type?

* must provide value

What was your first scleroderma symptom?

* must provide value

What year did you first develop Raynaud phenomenon?

* must provide value

What year did you develop your first scleroderma symptom other than Raynaud phenomenon?

What was your occupation when you developed your first symptom?

* must provide value

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What occupation(s) did you have for the 10 years preceding your first symptom?

* must provide value

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What is your current street number and name?

* must provide value

What is your current city?

* must provide value

What is your current state?

* must provide value

What is your current ZIP code?

* must provide value

What was the street number and name you lived on when you developed your first symptom?

* must provide value

In what city did you live when you developed your first symptom?

* must provide value

In what state did you live when you developed your first symptom?

* must provide value

What was your ZIP code when you developed your first symptom?

* must provide value

From what year to what year did you live there?

Please provide a street number, street name, city, state and ZIP code

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From what year to what year did you live there? ( if you had more than one address in the 10 years preceding your first symptom)

Please provide a street number, street name, city, state and ZIP code

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From what year to what year did you live there? ( if you had more than one address in the 10 years preceding your first symptom)

Please provide a street number, street name, city, state and ZIP code

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Please try to answer all questions. We may need to contact you if the information is incomplete or additional information is needed.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.