2024 Scleroderma Impact Survey Demographics Question Title * 1. What is your age? Question Title * 2. What is your gender? Man Woman Non-binary I prefer not to say Question Title * 3. What is your relationship status? Single Married Common Law In a relationship, living separately In a relationship, living together Widowed Prefer not to say Question Title * 4. What kind of community do you live in? Rural or small suburban (<10,000) Small or medium urban centre (10,000 - 500,000) Large urban centre (>500,000) Question Title * 5. Province? Ontario Quebec Manitoba Saskatchewan Alberta British Columbia Nova Scotia Newfoundland and Labrador Prince Edward Island New Brunswick Yukon Northwest Territories Nunavut Question Title * 6. Age at scleroderma diagnosis? Question Title * 7. Years since diagnosis? Question Title * 8. How long did it take you to be diagnosed? Question Title * 9. How many specialists did you see prior to diagnosis? Question Title * 10. What specialty did the doctor who diagnosed you work in? Question Title * 11. What type of scleroderma were you diagnosed with? Localized Systemic Question Title * 12. Are you a member of a patient support group? Yes No Question Title * 13. Would you be interested in joining a patient support group? Yes No Question Title * 14. In the past year, how many times have you been admitted into the hospital due to scleroderma? Question Title * 15. In the past year, how many days have you spent in the hospital due to scleroderma? Question Title * 16. In the past year, how many days have you spent in a clinic due to scleroderma? Next
