Welcome to   
 
  Stevens Johnson Syndrome Foundation  
   
        Make a Donation          
 Home   SJS Shop  SJS Fact Sheet   Contact Us 
 
  Navigation
  Support
  Awareness Events
  Medical Facilities
  Patient Resources
  Newsletters
  Media Center
  
Stevie Johnson Seagull SJS Mascot
[click here]

Help support the SJS Foundation by purchasing SJS awareness products.

 
SJS/TEN Survey

Note:
The purpose of this survey is to develop an International SJS/TEN Registry in the hopes of lobbying the United States Federal government for a mandatory reporting system of all adverse drug reactions.

Your name address and phone number will be kept confidential unless you choose to share that information by checking the consent box at the bottom of this form



Name: *
Address:
City:
State:
Zip:
E-Mail Address: *
Phone Number:
What is your gender?:
Male,     Female
Ethnic background:
(Optional)
Did you have Stevens Johnson Syndrome?:
Yes,     No
Did you have Toxic Epidermal Necrolysis?:
Yes,      No
When did you have SJS/TEN?:
(Please list month and year)
Month: , Year:
What was your age when you had your SJS/TEN?:
Was your SJS/TEN from a drug, and if so please list the name?:
Were you hospitalized and if so for how long?:
What hospital were you hospitalized in?:
(This will assist us in helping future patients with names of facilities that have experience in treating SJS).
Was your case of SJS/TEN reported to the FDA by your physician OR you?: *
(Please, help us by reporting to FDA [ Click here ].)
Yes,      No
Would you be interested in being contacted by the media for an interview?:
Yes,      No
Would you be interested in participating in any SJS research study programs?:
Yes,      No
Please list complications you have experienced as a direct result of SJS:
(i, e,: dry eye syndrome, blindness, asthma?)
Would you like be contacted by other SJS patients in your area?: *
Yes,    No
I choose to share my information with other SJS patients: *
Yes,     No

Field marked with * are required..!
 
  How to help us
  Prayers
Prayer: 1)  Prayer: 1)
Prayer: 2)  Prayer: 2)
Prayer: 3)  Prayer: 3)
Prayer: 4)  Prayer: 4)
Prayer: 5)  Prayer: 5)
Prayer: 6)  Prayer: 6)
Prayer: 7)  Prayer: 7)
Prayer: 8)  Prayer: 8)
Prayer: 9)  Prayer: 9)
Prayer: 10)  Prayer: 10)
Prayer: 11)  Prayer: 11)
Prayer: 12)  Prayer: 12)
Prayer: 13)  Prayer: 13)
Prayer: 14)  Prayer: 14)
Prayer: 15)  Prayer: 15)
Prayer: 16)  Prayer: 16)
Prayer: 17)  Prayer: 17)
Prayer: 18)  Prayer: 18)

If you like to add your prayers, contact us
Please allow 48 hours to view your prayer.

  Top Stories
Story: 1)
Story: 2)
Story: 3)
 
Information for Donors: The Stevens Johnson Syndrome Foundation is a 501 (C) (3) tax-exempt corporation. All donations to the SJS Foundation are tax-deductible. [ Click here ] for Tax information.
© Copyright since 2001. All rights reserved. Contact Webmaster: Amit Khatri
Disclaimer | Privacy Policy