Please enter your e-mail address.  This will become your unique identifier.  Please use this same identifier with future surveys.  It will be used only for the stated purpose and will not be released or made public in any way.

            E-mail address here   

Question 1.  Based upon all available information, do you believe your skin condition is Pityriasis rubra pilaris (PRP)?

Yes
Possibly, but not sure.
No  (Please do not continue. This survey is only for those with PRP.)

Question 2.  This survey is being completed by:

Self - the person having PRP
Other - a relative or friend of the person with PRP

Question 3.  Who officially diagnosed your skin condition as Pityriasis rubra pilaris (PRP) ?  Select one.

Medical doctor ?
Self ?
Other health professional?  Specify 
Never officially diagnosed.

Question 4.  Which type of PRP was diagnosed?  Select one.

Type I      Classic adult
Type II     Atypical adult
Type III    Classic juvenile
Type IV    Circumscribed juvenile
Type V     Atypical juvenile
Type VI    Adult HIV associated 
Other, please specify 
Not specified or unknown

Question 5.  When did you first notice PRP symptoms on your skin - before any medical attention?

* * Select a month * * January February March April May June July August September October November December Not sure and * * year * * Prior to 1993 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004     Note: Provide a year if earlier than 1993. 

Question 6.  How long did it take to get a correct PRP diagnosis, after noticing the first symptoms?

Number of months and/or years

Question 7.  Prior to a correct PRP diagnosis, was there another and different diagnosis?

  No
Yes   What was the first different diagnosis? 

Question 8.  Have you ever used prescription medications to treat PRP?

No
Yes   Beginning with the first prescription, indicate the type of medication.

1st
2nd
3rd
4th
5th

Question 9.  How does the PRP look on your skin today?

PRP is NOT currently visible anywhere on my skin
PRP is currently visible on my skin

Question 10. How old were you when the first signs of PRP appeared?  Select an age group.

* * Select one * * Present at birth Less than 1 year old 1 to 10 years 11 to 20 years 21 to 30 years 31 to 40 years 41 to 50 years 51 to 60 years 61 to 70 years 71 to 80 years More than 80 years

Question 11.  What is your birth year?

   Enter year.  

Question 12.  What is your sex?

          Female
          Male

Question 13.  Date of this survey?

  The date is entered automatically.  

  Suggested Future Questions or Topics ( 3 lines maximum )

  Additional Comments ( 3 lines maximum )

Review your answers for completeness and then submit them with the SEND button.

On behalf of all PRP members, thank you for participating.