Question 1/17
Do you suffer from arthritis?
Yes
No
Question 2/17
Have you been diagnosed with any of the following types of arthritis?
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Osteoarthritis
Psoriatic Arthritis
Rheumatoid Arthritis
Lupus
Gout
Question 3/17
What medications do you take to treat your osteoarthritis arthritis? (Check all that apply)
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Acupuncture
Advil
Arava
Aspirin
Azuladine
Celebrex
Chondroitin
Enbrel
Euflexxa
Holistic Method
Humira
Hyalgan
Hylagan
Imunan
Kineret
Mobic
Motrin
Neoral
Orencia
Orthovisc
Plaquenil
Remicade
Rituxan
Supartz
Synvisc
Tylenol
Question 4/17
What symptoms do you have related to arthritis?
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Deep pains in Joints
Difficulty performing daily tasks
Bending difficulty
Stiffness in the AM
Joint Swelling
Question 5/17
In what part of your body suffers from arthritis?
Question 6/17
What do you use to treat your rheumatoid arthritis?
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Aleve
Arava
Azulfidine
Celebrex
Cimzia
Cytoxan
Dexamethasone
Enbrel
Etodolac
Euflexxa
Fish Oil
Humira
Hylagan
Imuran
Kineret
Lodine
Methotrexate
Minocycline
Mobic
Neoral
Orencia
Orthovisc
Plaquenil
Prednisone
Remicade
Rituxin
Simponi
Supartz
Synvisc
Voltaren
Question 7/17
With your rheumatoid arthritis, do you experience any of the following conditions?
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Severe Pain
Stiffness
Lack of Appetite
Fatigue
Fever
Other
Question 8/17
How have you been treating your gout?
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Check All
Colchine
Cortef
Kenalog
Medrol
Ibuprofen
Allopurinol
Probenecid
Question 9/17
How have you been treating your psoriatic arthritis?
Select
Check All
Prednisone
Ibuprofen
Humira
Enbrel
Remicade
Methotrexate
Imiran
Cyclosproine
Exercise
Weight loss/Diet
Aquatherapy
Question 10/17
Are you currently satisfied with your treatment?
Yes
No
Question 11/17
Please explain why are you dissatisfied with your current treatment
Question 12/17
Are you interested in changing your treatment?
Yes
No
Question 13/17
What treatment(s) are you interested in switching to
Question 14/17
Do you currently have medical insurance?
Yes
No
Question 15/17
Please select your current medical provider
Select Options
Aetna
BCBS
Cigna
Humana
United Health
Medicare/Medicade
Chubb
Global Life
Met Life
Mutual Life of Omaha
NY Life
State Farm
Question 16/17
What is the name of your provider?
Question 17/17
lease select the current medical coverage you have
Select Options
HMO
PPO
Medicare
Medicaid
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