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SJS/TEN Registry

Note:
The purpose of SJS/TEN Registry is to gather an accurate count of SJS/TEN patients and identify successful treatment plans.

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



Patients Name: *
Completing form on behalf of patient:
Yes     No
Address:
City:
State:
Zip:
E-Mail Address: *
Phone Number:
What is your gender?:
Male,     Female
Ethnic background:
(Optional)
Did patient survive?:
Yes     No
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).
What type of treatment did you receive?:
(check all that apply).
IVIG,    Steroids,    Supportive care,
Intubation,    Ocular,    N/A
  
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..!
 
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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.
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