CEIS/ARCO Survey – Chronic Spontaneous Urticaria (CSU)

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CEIS/ARCO Survey – Chronic Spontaneous Urticaria (CSU)
1

Who is filling out the questionnaire:

2

Age at onset of the disease:

(age in completed years at onset)
3

Age at diagnosis:

(age in completed years at diagnosis)
4

Severity of the condition:

5

Date of completion:

Select a date
6

Zip code of residence:

Use digits only
7

Gender:

8

Age:

(completed years)
9

Is the patient an adult?

10

Marital status:

11

Who do you live with?

Select an answer
12

Educational level:

Select an answer
13

Gross annual income (in euros):

Select an answer
14

Employment status:

Select an answer
15

Days of work (study) lost due to the disease in the last 3 months:

(excluding days lost due to the bureaucratic management of the therapeutic plan)
16

Days in which productivity was reduced even if they went to work (in the last 3 months)

17

Over the last 3 months, how has CSU affected your productivity at work?

Consider the days when you felt limited in the amount or manner in which you were performing your work, or on days when you produced less than you wanted, or days when you could not perform your work with the usual attention. If CSU only slightly affected your work, select a low number. If CSU had a large impact, select a higher number.
0 - Value 0: CSU has no effect on my work,
10 - Value 10: CSU completely prevented me from doing my work
Value 0: CSU has no effect on my work
Value 10: CSU completely prevented me from doing my work
18

If you have or had employment...

For reasons related to your illness, have you ever found yourself in a position where you had to:
19

Are you under a therapeutic plan?

Select an answer
20

How long have you been on a treatment plan?

21

If you are currently on a treatment plan, how many episodes of disease flare-ups have you experienced before starting the treatment plan?

22

How many episodes of disease flare-ups have you experienced during the treatment plan?

23

How much time does the bureaucratic management of your therapeutic plan take in terms of:

24

If you answered "Other" to the previous question, could you specify what this option refers to?

25

Have you experienced any difficulties in accessing or renewing the therapy?

26

If yes, for which of these situations have you had difficulties in accessing or renewing the therapy?

You may select more than one option
27

If you answered "Other" to the previous question, could you specify which situation you encountered difficulties in accessing and renewing the therapy?

28

Due to your discomfort related to CSU symptoms, have you had to request assistance from a parent/relative/friend to carry out your daily personal and/or professional activities?

Select an answer:
29

Gross annual income of the caregiver (in euros):

Select an answer:
30

Professional status of the caregiver:

Select an answer:
31

For reason related to the assistance to the person with CSU, has the caregiver ever been in a position to...

(You may select more than one option)
32

Days of work (study) lost by family members (caregiver) due to assisting the CSU patient (in the last 3 month):

In this section, we will ask you for information on the expenses you have incurred, including both medical and non-medical costs. 

33

Means of transport used to go to visit:

You may select more than one option
34

Average time (in minutes) taken to go to a control visit (one-way):

35

Does the CSU patient have exemption for CSU?

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36

If the person with CSU has been hospitalized or has had emergency department visits in the past 12 months, could you indicate how many times?

Write in the empty fields below. If you did not use the service, enter zero.
37

Could you indicate the number of visits in the last 12 months and whether they were covered by the National Health Service (NHS) or performed privately?

Write in the empty fields below. If you did not use the service, enter zero.
38

Could you indicate the expense you incurred for private visits made in the last 12 months? (Allergist/Immunologist/Dermatologist)

39

Could you indicate the expense you incurred for private visits made in the last 12 months? (Pulmonologist)

40

Could you indicate the expense you incurred for private visits made in the last 12 months? (Other)

41

Considering the medications and/or therapies you have used to treatment of CSU (including off-label treatments), could you please indicate which ones are reimbursed by the National Health Service (NHS)?

Select one or more answers
42

42. For medications not reimbursed by the National Health Service (NHS), how much have you spent in the last 6 months for the purchase of: Antihistamines

Select an answer
43

Corticosteroids

Select an answer
44

Cyclosporine

Select an answer
45

Creams, ointments, etc

Select an answer
46

Omalizumab

Select an answer
47

Other

Select an answer
48

If you answered "Other," can you specify which medication it is?

49

Have you incurred any unexpected costs for managing CSU that were not included in the questionnaire and are not reimbursed by the National Health Service?

Select an answer
50

If yes, what are they

Write in the empty fields below

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