Donate Today!
×
Home
About
Information
Events
What is Degos?
External Links
For Caregivers
For Doctors
An overview
Diagnosing Degos
Prognosis
Treatments
Whats New
Galleries
Photo Gallery
Video Gallery
Degos Disease Symposium
Research
Articles & Papers
Donate
How to help
Questionnaire
Histopathological Criteria
Malignant Atrophic Papulosis
Patients
My Journey with Degos
Patient Stories
Where in the world?
Contact
Support Network
Doctors
MENU
Questionnaire
Health History Survey for Patients with Malignant Atrophic Papulosis/MAP or Degos Disease
Download
Name
*
First
Middle
Last
Maiden name
Date of Birth
*
Sex
*
Male
Female
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Contact Number
*
Email
*
Caregiver
Name
First
Last
Relationship of Caregiver
Contact Number
Patients Health
Color of skin
Albino
White
Pink
Yellow
Tan
Brown
Black
Other
Please specify
Color of eyes
Hazel
Green
Blue
Brown
Black
Other
Please specify
What childhood illnesses do you or did you have?
Antibiotics Resistance
Autism Spectrum Disorders (ASDs)
Birth Defects
Cancer
Cerebral Palsy
Chickenpox
Conjunctivitis (Pink Eye)
Developmental Disabilities
Diabetes
Diphtheria
Down Syndrome
Ear Infection
Fetal Alcohol Spectrum Disorders (FASDs)
Flu
Foodborne Diseases
Group B Strep
Hand, Foot and Mouth Disease
Hearing Loss
Hepatitis
Influenza (Flu)
Intellectual Disability
Jaundice (Kernicterus)
Kernicterus (Jaundice)
Medicine, Cold & Cough
Parasitic Diseases
Pertussis (Whooping Cough)
Recreational Water Illness (RWI)
Rotavirus
SIDS
Sinus Infection
Sore Throat
Spina Bifida
Vision Impairment
ADHD—Attention-Deficit /Hyperactivity Disorder: Quick Facts
ADHD—Attention-Deficit /Hyperactivity Disorder: What CDC Says
Asthma
Children’s Mental Health
Developmental Disabilities
H1N1 (Swine Flu)
Language Disorders
Learning Disorders
Lice
Measles
Meningitis
Mumps
Obesity
Polio (Poliomyelitis)
Rubella (German measles)
Sinus Infection
Tourette Syndrome
Anxiety
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
HPV (Human Papillomavirus)
Skin Cancer
STDs
Tetanus
Other
Please specify
Do you have any other diseases affecting your circulatory system (heart and blood vessels)?
Coronary Artery Disease (CAD)
Hypertension
Peripheral Vascular Disease (PVD)
Congestive Heart Failure (CHF)
Do you have any other diseases effecting your skin?
Acne
Alopecia Areata
Atopic Dermatitis
Cicatricial Alopecia
Epidermolysis Bullosa
Ichthyosis
Lichen Sclerosus
Pachyonychia Congenita
Pemphigus, Psoriasis
Raynaud’s Phenomenon
Rosacea
Scleroderma
Vitiligo
Do you have any other chronic diseases or medical conditions?
At what age did you develop your first skin lesion?
*
How many skin lesions do you have right now?
1 to 19
20 to 39
40 to 59
60 or more
Other than classic porcelain white macules with red edges, what are the other characteristic(s) of your Cutaneous Degos skin lesions?
Itching
burning
swelling
pain
redness
drainage
ulcerations
Other
Please specify
Did you have a punch biopsy done to diagnose your Cutaneous Degos?
What treatment(s) have you used for your skin lesions?
Hydrocortisone creams
Steroids creams
Moisturizing Creams
Aspirin
Dipyridamole
Anticoagulants
Ticlopidine
Pentoxifylline
Prostaglandin E1, and Interferon alpha-2a
Intravenous Immunoglobulin
Infliximab
Corticosteroids
Other
Please specify
Did you travel out of your country in the year prior to diagnosis?
Yes
No
Do you have any symptoms of Systemic disease?
Abdominal pain
bowel perforation
Diarrhea
chills
fever
nausea
vomiting
Sepsis
Aphasia or difficulty communicating
eye issues
Seizures
Stroke
Paralysis
Other
Please specify
What internal organs or organ systems are involved or suspected to be involved?
Musculoskeletal system; bones and muscles
Circulatory system; Heart and blood vessels
Digestive system; Bowel
Endocrine system
Urinary system
Lymphatic system
Immune system
Respiratory system; Lungs
Nervous system; Brain and spinal cord
Reproductive system
What treatment(s) have you used for your Systemic Degos disease?
Hydrocortisone creams
Steroids creams
Moisturizing Creams
Acetylsalicylic acid
Aspirin
Dipyridamole
Persantine
Anticoagulants
Ticlopidine
Ticlid
Pentoxifylline
Trental
Pentoxil
Prostaglandin E1
Alprostadil
Interferon alpha-2a
Pegasys
Intravenous Immunoglobulin
Infliximab
Remicade
Corticosteroids
Treprostinil
Remodulin
Eculizumab
Soliris
Tocilizumab
Actemra
Other
Please specify
Physician Information
Physician - Caring for your Degos disease?
Medical specialty
Physician Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Additional Comments
Comments
This field is for validation purposes and should be left unchanged.
Copyright © 2021 Degos Disease. All Rights Reserved.
Website Designed
and Developed by
PRM Group Inc
Follow via Facebook
Follow via Linkedin
Follow via Twitter
Follow via Youtube
Follow via Google
Follow via Pinterest
Follow via Instagram
Mail to