General Questions

General Questions

HS-USA > HS-USA Patient Surveys > General Questions

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ABOUT YOU

1. What is your gender?

	Male
	Female

2. What is your skin type / color?

	very dark
	dark
	olive
	medium / tan easily
	fair
	very fair

3. What is your weight (BMI if you know)?

	underweight (BMI < 18.5)
	normal (BMI 18.5 - 23.9)
	slightly overweight (BMI 24 - 26.9)
	overweight (BMI 26 - 29.9)
	obese (BMI > 30)

4. How old are you?

7. What is your ethnic group / heritage?

	African
	Arabic
	Asian
	Caucasian
	Hispanic
	Native American / Aboriginal
	Pacific Islander
	Mixed
	Other

8. Where do you live?

	City
	Town
	Suburban
	Rural
	Wilderness

9. Are you currently employed?

	full-time
	part-time
	unemployed
	student
	home-maker
	on disability for HS
	on disability for other reasons
	retired

10. Are you (or have you ever been) exposed to pollutants in your work environment?

	Don't know
	No
	Yes

11. If you answered YES above, can you tell us what kind of pollutants?

12. Additional comments for the ABOUT YOU section:

ABOUT HS

20. How long have you suffered from HS?

21. What was your age when HS first appeared?

	0-10
	11-20
	21-30
	31-40
	41-50
	51-60
	60+
	don't remember

22. Where on your body did HS start first?
(multiple answers possible)

	Armpits
	Breasts and bra line
	Buttocks
	Groin / labia / scrotum
	Thighs
	Belly
	Neck / ears / face
	Head / scalp
	Other

23. If other, please specify:

24. What was your weight when HS first appeared?

	underweight
	normal
	slightly overweight
	overweight
	obese

25. Did you or someone close to you smoke when your HS first appeared?

	Yes, I was a heavy smoker
	Yes, I was a casual smoker
	Yes, I was exposed to second-hand smoke
	No, but my parents were smokers
	No, I was not exposed to cigarette smoke

26. Which parts of your body have been affected with HS over time?
(multiple answers possible)

	Armpits
	Breasts and bra line
	Buttocks
	Groin / labia / scrotum
	Thighs
	Belly
	Neck / ears / face
	Head / scalp
	Other

27. If other, please specify:

28. At what stage would you discribe your HS today?

	Stage 1 (single or multiple isolated abscesses, without scarring or sinus tract formation.)
	Stage 2 (Single or multiple recurring abscesses, some scarring and sinus tract formation)
	Stage 3 (Diffuse or broad, recurring, involvement across a regional area with multiple interconnected sinus tracts and significant scarring.)

29. What weather conditions make your HS worse?
(multiple answers possible)

	Hot weather
	Humid weather
	Dry weather
	Cold weather
	Extreme temperature fluctuations
	Weather does not change anything
	Don't know

30. Does stress make your HS worse?

	Yes, definitely!
	I think so, but I'm not certain
	Stress does not have a negative effect
	Can't tell

31. Are flare-ups associated with a strong itch?

	Yes, the itch comes first
	Yes, but only when I take antibiotics
	Yes, it always itches
	Yes, it starts itching when it heals
	No, it usually doesn't itch

32. As far as you know, what are your three main triggers for flare-ups?

33. Have you ever experienced a remission for more than 3 months?
(If you select No, skip to question #38)

34. Can you pinpoint what brought you into remission?

35. Are you still in remission today?

	Yes
	No

36. If you answered NO to the previous question, can you pinpoint what brought the HS flareups back?

37. Additional comments for the ABOUT HS section:

FAMILY HISTORY

41. Do you have family members who have HS?

	I don't know
	No
	Yes

42. If yes, please tell us about them - how many and how are they related to you?

43. Do you have family members with autoimmune problems?

	Yes
	No
	Don't know

44. Additional comments for the FAMILY HISTORY section:

YOUR GENERAL HEALTH

51. Are you often tired?

	Yes, almost always
	Yes, often
	No
	Not sure

52. Which other conditions do you have now or have had in the past?
(multiple answers possible)

53. Please tell us about any other health problems:

54. Do you have any allergies?

	Yes
	No
	Don't know

55. If you answered yes, please tell us what allergies:

56. Do you have frequent yeast infections (candida)?

	Yes, often
	Yes, occasionally
	Rarely
	Never
	Don't know

57. Do you suffer from depression?

	Yes, I have been diagnosed and I have been taking medication
	Yes, I have been diagnosed but I don't do anything about it
	Yes I think so, but I have not been officially diagnosed
	No

58. Additional comments for the YOUR GENERAL HEALTH section:

FEMALES ONLY

61. Does your HS get worse around your menses?

	Yes
	No

62. Do oral contraceptives affect your HS?

	Yes, it gets worse
	Yes, it gets better
	No change
	I never took the pill
	Can't tell

63. If you answered yes above, what pill(s) where you taking?

64. How does your HS change during pregnancy?

	It gets significantly worse
	It gets significantly better
	It fluctuates (by trimester)
	No significant change
	I've never been pregnant

65. Additional comments for the FEMALES ONLY section:

MALES ONLY

71. Does your HS seem to have a cycle? Does it fluctuate?

	Yes, it cycles regularly
	It fluctuates unpredictably
	I can tell what brings it on
	No, it is always bad

72. Please elaborate...

73. Additional comments for the MALES ONLY section:

PAIN

81. On a scale of 1-10 (1 being no pain and 10 being excruciating pain) what is your general HS pain level?

82. Do you currently take pain medicaion for your HS?

	Yes, all the time
	Yes, occasionally
	Very rarely
	Never (skip to question #86)

83. Does your pain medication effectively manage your pain?

	Yes
	No

84. What types of pain medication do you take?
(multiple answers possible)

	Over the Counter (eg., Tylenol, Advil)
	Prescribed, anti-inflammatory (eg., Motrin, Ibuprofen)
	Prescribed, non-narcotic (eg., Davocet, Lortab, Vicodin)
	Prescribed, narcotic (eg., Morphine, Demerol)
	Other

85. If you selected other, please list:

86. If you're not taking pain medication(s), why?

	Pain is not a problem for me
	Even though I've asked my doctor about pain medication, he/she doesn't think I need it
	I am able to manage pain using natural remedies
	I have a very high pain threshold
	Other

87. If other, please describe:

88. Additional comments for the PAIN section:

WRAPPING IT UP...

91. Do you have any other general comments that apply to the topics covered in this survey?

92. Would you like to tell us your email address?
(this is completely voluntary, please do not answer this question if you would like to remain anonymous)

Thank you for taking the time to answer our questions!
Now, hit the Submit button to add your answers to the database and tally results for this survey.

HS-USA Patient Surveys