Surface Sign ups

Welcome to Surface. To get started we first have a few questions to ask.

Get started

press ENTER

What is your name?

Ok

press ENTER
What is your email?

Ok

press ENTER
Please accept our data privacy policy before continuing http://privacy.surface.ai.
Choose as many as you like

A
Accept
Ok

press ENTER
How much is your skin bothering you?
Choose as many as you like

A
Not at all

B
A little

C
A lot
Ok

press ENTER
Have you been prescribed treatment?
Y
Yes

N
No
Do you feel your treatment works well enough?
Choose as many as you like

A
It doesn’t

B
It does a little

C
Somewhat

D
Yes, a lot
Ok

press ENTER
How effective do you think your treatment is?
Have you been taking your treatment as prescribed by your doctor?
Choose as many as you like

A
Yes

B
No
Ok

press ENTER
Why have you not been taking your treatment as prescribed by your doctor?

Ok

press ENTER
How much do you consider current treatment as an inconvenience?
Choose as many as you like

A
It isn't

B
It has a little

C
Somewhat

D
A lot
Ok

press ENTER
Does your psoriasis embarrass you?
Choose as many as you like

A
It doesn’t

B
It does a little

C
Somewhat

D
Yes, a lot
Ok

press ENTER
How does it embarrass you?

To add a paragraph, press SHIFT + ENTER

Ok

press ENTER
Do you dress differently because of your psoriasis?
Y
Yes

N
No
How do you dress differently?

To add a paragraph, press SHIFT + ENTER

Ok

press ENTER
Does psoriasis affect you during work, study, sports or daily activities such as shopping or cleaning?
Choose as many as you like

A
It doesn’t

B
It does a little

C
Somewhat

D
Yes, a lot
Ok

press ENTER
How does it affect you during these activities?

To add a paragraph, press SHIFT + ENTER

Ok

press ENTER
Do you feel or act differently towards others in your life because of psoriasis?
Y
Yes

N
No
Can you describe how psoriasis affects how you feel or act with others?

To add a paragraph, press SHIFT + ENTER

Ok

press ENTER
Does psoriasis affect your social life?
Y
Yes

N
No
Please rate how you think psoriasis affects your social life.

0 is equivalent to not at all
Please describe in a few words how psoriasis affects your social life?

To add a paragraph, press SHIFT + ENTER

Ok

press ENTER
Does your psoriasis have an impact on you with regards to intimacy or sex?
Y
Yes

N
No
How much does psoriasis have an impact on you with regards to intimacy with others?
When you think about being intimate, how do you feel?

To add a paragraph, press SHIFT + ENTER

Ok

press ENTER
Please rate how much you feel:

Continue

press ENTER
Stressed
1 is not at all, 5 is very stressed
Anxious
1 is not at all, 5 is very anxious
Sad or unhappy
1 is not at all, 5 is very sad or unhappy
Can you sum up in a few words why you feel this way?

To add a paragraph, press SHIFT + ENTER

Ok

press ENTER

Thanks for filling out the questionnaire. We will email you as soon as we have looked into your answers.