Plaque Psoriasis Questionnaire Preferred Location:*Please SelectLa Casita - 326 W. Craig PlaceSonterra - 18707 Hardy Oak BoulevardPatient Name: First Last Please answer these questions to start a discussion with your Healthcar Provider about your plaque psoriasis.1. Do you consider your plaque psoriasis to be :MildModerateSevereWhy?2. Indicate where plaque psoriasis is located on your body. Front View : Back View : 3. How embarrassed do you feel because of your plaque psoriasis symptoms?1234564. Does plaque psoriasis affect the way you dress?YesNo5. How satisfied are you with your current treatment?Not Applicable123456Why? or Why Not?6. What would you like your plaque psoriasis treatment to achieve?7. Would you like to learn about the risks and benefits of the treatment options available?YesNoe-Signature :*Date This iframe contains the logic required to handle AJAX powered Gravity Forms.