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Did you come to our site to gain information for yourself, or for another person?

Your interest in the Site is as:

For Patients and Non-dentists:

Have you participated in our interactive discussion group either by listening or through interaction?

Have you found the discussion groups helpful?

What day of the week would be the best time for you to participate in our discussion group?

What general time of day would be the best for you? (Please use the Central USA time zone for this answer)

If Evening is best, which time?

Have you asked us for a referral to a facility knowledgeable in Lichen Planus?

Were you satisfied with the treatment you received from the site to which you were referred?

Was your inquiry answered by us in a reasonable amount of time?

Do you feel that the site is providing you with needed information and is overall worthwhile?

Please rate your satisfaction level overall on the scale

Which of the following would you like to see increased and expanded.  Please indicate by using #1 as the most useful with consecutive numbers to follow.

• Educational materials on oral lichen planus such as journal articles.
   
•  Health related material on nutrition, exercise and life-style.
   
•  Stress management educational material.
   
•  Psychological material such as optimism, coping skills.
   
•  Most frequently asked questions with our responses.
   
•  Practitioner's page with short publications contributed by theexperts in the field of oral lichen planus treatment. 
• Other:

If you are the person who has been diagnosed with lichen planus, please answer the following questions.  If you entered our site for someone else who has been diagnosed with lichen planus, please DO NOT answer the questions below.  The diagnosed person may want to enter the site and answer the entire survey. Thank You.

Who is the person who monitors your lichen planus:

• General Dentist
   
•  Pathologist
   
•  Periodontist.
   
•  Oral Medicine Dentist
   
•  Oral Surgeon
   
•  Ear, Nose & Throat
   
•  Physician
   
• Other:    

How often does this person check the Lichen Planus?
(Please list in months:)

How long have you had Lichen Planus?

 Recently diagnosed within the last year

Do you have now, or have you ever had, the following conditions:

• Heart Problems
   
•  Respiratory Diseases
   
•  Gastrointestinal Diseases.
   
•  Arthritis
   
•  Rheumatism
   
•  Thyroid Conditions
   
•  Diabetes
   
•  Blood Dyscrasias
   
•  Neurological Disturbances
   
•  Psychological Disturbances
   
•  Allergies
   
•  Nutritional Deficiencies
   
•  Malignancy or Growth
   
• Other:    

What medications are you currently using to control your Lichen Planus

 Topical Corticosteroids

Do you have an oral yeast infection in addition to the oral lichen planus?

 Yes

Which of the following appear to make the Lichen Planus worse?

 Flavoring Agents

• Cinnamon
   
•  Peppermint
   
•  Wintergreen.
   
•  Spearmint

Do you have lichen planus on any surface areas of the body?

 Yes

 No

If YES, which family member(s)?

Your blood type is …

 A     B     O     AB

Your Lichen Planus is ...

 Erosive             Reticular          Don't Know

What brands of oral hygiene products do you use? Please List:

What educational information were your given concerning your oral lichen planus when you were initially diagnosed?

 Extensive        Moderate        Minimal

From what sources have you gained information?
(Check all that apply)

 Public Library

 Other  (please specify):

Were you ever given any written educational materials on lichen planus?

 Yes

For Women:

Have you been able to relate your Lichen Planus with hormonal changes?

 Yes

At what point in the menstrual cycle do the lesions appear to become more apparent??

 Before my period

Have you ever had a biopsy for vaginal Lichen Planus?

 Yes

If you have vaginal Lichen Planus do you have oral lesions also?

 Yes

Have you ever been treated for vaginal:

 Pain

What medications do you use for vaginal lichen planus -- please list:

For Dentists:

What is your specialty area:

How long have you practiced?

Please Read BEFORE submitting form: Thank you very much for participating in this important survey. It will greatly help us in making this service better for you and all those who suffer from this condition. When you are sure your responses are accurate to your satisfaction, click the Submit button ONLY ONCE.

NO ONSCREEN ACKNOWLEDGEMENT WILL BE GIVEN. Thank you again for your participation. You are helping us in a much needed service.

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