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Contact
Do I Have A Case?
Back
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Step
1
of
10
10%
Who are we speaking to?
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Who
*
I was diagnosed with SJS
A loved one of mine was diagnosed with SJS
When were you diagnosed with SJS?
Select One Option
When were you diagnosed
*
Less than 1 year ago
1-2 years ago
2-3 years ago
3-4 years ago
More than 4 years ago
Were you hospitalized as a result of SJS?
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You Hospitalized
Yes
No
How long were you hospitalized?
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How long you hospitalized
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
What drug caused your SJS?
Select Response
The Cause of SJS
*
Select One
Advil
Azithromycin
Children’s Advil
Dilantin
Flagyl
Libtayo
Tegretol
Xeljanz
Zithromax
Zosyn
Other
Unknown
You Selected Other. Please Specify Name of Drug or Select Unknown.
*
When were they diagnosed with SJS?
Select One Option
When were they diagnosed
*
Less than 1 year ago
1-2 years ago
2-3 years ago
3-4 years ago
More than 4 years ago
Were they hospitalized as a result of SJS?
Select One Option
They Hospitalized
*
Yes
No
How long were they hospitalized?
Select One Option
How long they hospitalized
*
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
What drug caused their SJS?
Select Response
The Cause of SJS
*
Select One
Advil
Azithromycin
Children’s Advil
Dilantin
Flagyl
Libtayo
Tegretol
Topamax
Xeljanz
Zithromax
Zosyn
Other
Unknown
You Selected Other. Please Specify Name of Drug or Select Unknown.
*
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*
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