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1
Separator label - en Id: 149213
subj1
PTh
Auactdur
nhome
othInsur
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i
Visit
Date of visit
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Unknown (nk)
*
/
/
*
Subject ID
In Project ID
Gender
M
F
Age
Date of Inclusion
Page
Site
Status
I. General Information
1. As a result of your psoriasis, how often during the last 12 months have you been
hospitalised on an inpatient basis (at least 1 night)
Times
2.1 Do you work?
Yes
No
2.2
if yes:
Full-time (35 hours and more)
Part-time or hourly
Leave of absence (parental leave or similar)
Trainee, professional reorientation
2.2
if no:
Pensioners / retired civil servants, early retirees
Housewife / house husband
Scholar, student
Unemployed
Economically inactive due to other reasons
Hours per week
2.3 If working: On how many days during the last 12 months were you unable to work due to psoriasis?
Days
2.4 Are you currently not able to work due to psoriasis?
Yes
No
Days
3. What is your marital status?
Married
Single
Divorced
Widowed
4. Do you live alone?
Yes
No, with
additional persons in household
5. What kind of health insurance do you have?
Statutory health insurance without complementary insurance
Statutory health insurance with private complementary insurance
Just private health insurance
No health insurance
Other, namely
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