Profile:
Name*
Surname*
Email Address*
Contact Number*
Fax Number*
Company
Occupation*
Date of Birth*	Month January February March April May June July August September October November December Day Year
Sex*	Male Female
Race
Do you suffer from psoriasis?	Yes No
What type of psoriasis?
Do you suffer from psoriatic arthritis?	Yes No
What type of psoriatic arthritis?
Are you currently undergoing treatment?	Yes No
If so, what treatment?
How many years have you had the condition?
Do other members of your family have the same conditions?	Yes No
On a scale of 1 to 10, how much does psoriasis/psoriatic arthritis have a negative effect on your life, 1 being no problem and 10 being extremely severe?
Other Comments:
Please note that the above information is confidential and is required for record purposes only