UTSW Dermatology Clinical Trial- Lichen Sclerosus (LS)

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Required format:

n4WQeHrY7VAn7we3s8x2v7kx8wM

Thank you for your interests in the UTSW Dermatology Clinical Trials!

Your answers will be used only to determine whether you may qualify for this study. They will be kept confidential and stored securely. Only authorized study staff will have access to your information, and it will not be shared outside the study team.

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Gracias por su interés en los Ensayos Clínicos de Dermatología de UTSW.

Sus respuestas se utilizarán únicamente para determinar si puede calificar para este estudio. Se mantendrán confidenciales y almacenadas de manera segura. Solo el personal autorizado del estudio tendrá acceso a su información, y esta no se compartirá fuera del equipo del estudio.

Record ID

What is your preferred language?

* must provide value

English Spanish

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What is your age?

* must provide value

Have you ever been diagnosed with lichen sclerosis?

* must provide value

Yes

Not sure

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If "Not sure", have you experienced chronic itching, irritation, or skin changes in the genital or anal area?

Yes

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Do you currently have active symptoms related to lichen sclerosus?

* must provide value

Yes

Not sure

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Where do you experience symptoms? (Select all that apply)

* must provide value

Vulva

Perineum (area between vagina and anus / scrotum and anus)

Perianal area

Penis

Scrotum

Other

Not sure / don't know

If 'Other,' please specify the location(s).

How would you rate your symptoms today?

* must provide value

Mild: Occasional itching or discomfort

Moderate: Frequent itching, soreness, or burning)

Severe: Constant symptoms or pain interfering with daily life

Not sure

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Thank you! Please provide your first and last name, along with your preferred contact information, so our team can reach out to you.

First name:

Last name:

Phone:

Email:

¿Cuál es su edad?

* must provide value

¿Alguna vez un proveedor de atención médica le ha diagnosticado liquen escleroso?

* must provide value

Sí

No estoy seguro/a

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Si seleccionó "No estoy seguro(a)", ¿ha tenido picazón crónica, irritación o cambios en la piel en el área genital o anal?

Sí

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¿Actualmente tiene síntomas activos relacionados con el liquen escleroso?

* must provide value

Sí

No estoy seguro/a

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¿En qué área presenta los síntomas? (Marque todas las que correspondan)

* must provide value

Vulva

Perineo (área entre la vagina y el ano / el escroto y el ano)

Área perianal

Pene

Escroto

Otro

No estoy seguro/a / no lo sé

Si selecciona "Otro", por favor especifique la(s) ubicación(es).

¿Cómo describiría sus síntomas hoy?

* must provide value

Leve: picazón o molestia ocasional

Moderado: picazón frecuente, ardor o dolor

Grave: síntomas constantes que interfieren con su vida diaria

No estoy seguro/a

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¡Gracias! Por favor, proporcione su nombre y apellido, junto con su información de contacto preferida, para que nuestro equipo pueda comunicarse con usted.

Nombre:

Apellido:

Teléfono:

Correo Electrónico:

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