Registration for PsorCoach 2018
PsorCoach Program is open to Filipino psoriasis patients who wants to learn more about their condition and who are willing to be guided in managing their psoriasis.

PsorCoach Program does NOT in any way give any medicines, treatment or any financial help. This program is solely a coaching system where we give you information and educate you about psoriasis as a Non-Communicable Disease (NCD). This program aims:

- to help you manage your psoriasis by having the right information about the disease
- to connect you with the right hospitals and doctors who is passionate about psoriasis
- to prevent self-medication and prevent abuse of medicine
- to promote adherence to treatment and continuous follow up with a physician
- to provide emotional support with our community

By signing up in this program, you agree to be contacted and be monitored by our PsorCoach Team. We hope that through this program, you will learn more about psoriasis and how to manage your condition.

Last Name *
Your answer
First Name *
Your answer
Address *
Your answer
City / Province *
Your answer
Country *
Your answer
Age *
Your answer
Gender *
Status *
What is your occupation *
Contact # *
Your answer
Email *
Your answer
Facebook Name
Your answer
Did a doctor diagnosed you of psoriasis? *
Which doctor did you visit for your psoriasis? *
Required
What type is your psoriasis? *
Required
No. of Years with Psoriasis *
Your answer
Who is your current physician? *
Name of doctor that is looking after your psoriasis.
Your answer
Which doctors have you visited besides a dermatologist? *
Required
What other illness have experienced before and experiencing now? *
This will help us check your medical history. Please check pass and current illness that you have experienced.
Required
Have you suffered from depression? *
Have you thought of committing suicide before? *
Have you seek professional help about your depression? *
Have you heard of PsorPhil? *
How did you hear about PsorPhil *
Your answer
Have you attended any events of PsorPhil? Pls check the events that you have attended.
Are you a member of any PsorClub Chapter? Pls indicate the name of your PsorClub
Your answer
How did you hear about PsorCoach Program? *
Your answer
Have you been part of PsorCoach before? *
If Yes, who was your previous PsorCoach? *
Your answer
Why do you want to enroll again in PsorCoach? *
Your answer
How do you want to talk with your PsorCoach? *
Required
In case of Emergency, who should we contact? *
Name of keen, family or guardian
Your answer
Contact number of your family, guardian or next of keen *
Your answer
Please choose your preferred time of contact *
Required
What is your expectation in enrolling in PsorCoach Program? *
Your answer
What medicines and treatment have you tried? *
Your answer
What medicines and treatment are you currently using? *
Your answer
How long have you been using these medicines and treatment? *
Your answer
When was the last time you had a check up? *
Your answer
Are you personally enrolling yourself to PsorCoach Program? *
If not, what is your relation to the person?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms