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i
Visit
Date of visit
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Unknown (nk)
*
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Subject ID
In Project ID
Gender
M
F
Age
Inclusion
Page
Site
Status
l. General Information
1. In which year were you first diagnosed with psoriasis?
Year
2. Do you have first-degree relatives (children/parents/siblings) who suffer from/have suffered from psoriasis?
Yes
No
3. As a result of your psoriasis, how often during the last 5 years have you been
hospitalised on an inpatient basis (at least 1 night) ?
Times
4.1 Do you work?
Yes
No
4.2 If yes:
Full-time (35 hours and more)
Part-time or hourly
Leave of absence (parental leave or similar)
Trainee, professional reorientation
4.2 if no:
Pensioners / retired civil servants, early retirees
Housewife / house husband
Scholar, student
Unemployed
Economically inactive due to other reasons
Hours per week
4.3 If working: On how many days during the last 12 months were you unable to work due to psoriasis?
Days
4.3 Are you currently not able to work due to psoriasis?
Yes
No
For [x] Days
5.1
Do you suffer from joint pain?
Currently
Previously
Never before
5.2
Have you been diagnosed with psoriasis arthritis?
Currently
Previously
Never before
6. What is your marital status?
Married
Single
Divorced
Widowed
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