If you or someone you care about is living with psoriasis, we need your help! We are building a grass roots army of volunteers to drive forward our agenda with Congress, the media, and the general public.

Whether you are able to help once a year or once a week, we need you involved. Please take a few minutes to answer some or all of the following questions. The only requirement is that you provide a working email address--all the other questions are OPTIONAL and you should ignore any questions you do not want to answer. Then simply click SUBMIT and you will be part of our growing team.

As you will see, there are many ways you can help our work on behalf of the psoriasis patient community. Thanks and together, we will make a difference in the lives of everyone with psoriasis and psoriatic arthritis!

Email Address:
First Name:
Last Name:
Street address 1:
Street address 2:
City:
State of residence:	------- Non-US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Telephone:
Age:
Male or Female:	Male Female
Do you have psoriasis?	Yes No
Do you have psoriatic arthritis or arthritic symptoms?
Yes No
Do any of the following have psoriasis or psoriatic arthritis:
Your child Grandchild Parent Sibling Spouse Significant other Other relative Friend
Are you willing to speak to the media about psoriasis or psoriatic arthritis?
Yes No
Are you willing to speak or write to your lawmakers about psoriasis or psoriatic arthritis?
Yes No
Are you involved in a local patient support group?
Yes No
Might you be interested in attending one?
Yes No
Might you be interested in helping to launch one?
Yes No
Are you willing to help Psoriasis Cure Now with fundraising efforts?
Yes No
Are you willing to participate in public events related to psoriasis/psoriatic arthritis?
Yes No
Is your psoriasis visible when you are in public, or is it not visible and/or covered up?
Visible Not-Visible
Do you personally know any Members of Congress, US Senators, Governors or entertainment stars (actors, musicians, athletes, etc.)?
Yes No     If yes, please describe:
Are you willing to ask your physician (dermatologist, rheumatologist, general practitioner) to distribute to their patients materials prepared by Psoriasis Cure Now?
Yes No
Are you willing to be photographed with your psoriasis for public dissemination?
Yes No
Are you now using any of the following:
Amevive Cyclosporine (Neoral) Dovonex Elidel Enbrel Humira Methotrexate Prednisone Protopic PUVA Raptiva Remicade Soriatane UVB
Have you previously used any of the following:
Amevive Cyclosporine (Neoral) Dovonex Elidel Enbrel Humira Methotrexate Prednisone Protopic PUVA Raptiva Remicade Soriatane Tegison UVB
Would you consider participating in a clinical trial for an experimental treatment for psoriasis or psoriatic arthritis?
Yes No
People of color with psoriasis often face unique challenges. Are you a person of color?
Yes No     If yes, please explain:
How long have you had psoriasis?	------- Fewer than 5 years 5-20 years More than 20 years
How long have you had psoriatic arthritis?	------- Fewer than 5 years 5-20 years More than 20 years
When did you first get psoriasis?	------- Childhood Teens Your 20s Your 30s Your 40s Your 50s 60s or later
Do you currently have health insurance?
Yes No
If you currently have health insurance, rate it 1 to 5 (5 being best) based on how well they cover your psoriasis/psoriatic arthritis treatment(s).
------- 1 2 3 4 5
If you have a spouse/significant other, would that person be willing to speak to the media about psoriasis?
Yes No
Could you come to Washington, DC to meet with your lawmakers or their staffs?
Yes No