Xerostomia Questionnaire

Thank you for your willingness to share your experience with xerostomia. We kindly ask that you complete all questions below. Your responses may be brief; upon determination of the best suited role for you, we may request additional information and provide further direction.

We are seeking participants who will serve as “Discussion Starters” for one of our two panels in an upcoming Externally Led Patient-Focused Drug Development Meeting on xerostomia. The first panel is focused on symptoms and the second is focused on treatments. As a Discussion Starter, you would be asked to share your personal experience in living with xerostomia during the meeting. Your contribution would be live, so you would not need to prepare anything in advance, however we would require that you attend the virtual meeting on Thursday, August 19 from 10am – 3:30pm in addition to a one-hour rehearsal on August 18th between 10am – 1pm (the specific time is to be determined).

Name*
First Last
Email*
Phone
Address*
City State / Province / Region Country
Do you or a loved one experience xerostomia (dry mouth) as a result of a disease, disorder, medication, or other condition?*
If yes, what is the cause of xerostomia?*
For Example: Xerostomia can be the result of radiation damage to the salivary glands in people who have undergone radiation treatment for head/neck cancer.
How would you rate the severity of your or your loved one's xerostomia?*
How has xerostomia most impacted your or your loved one's life? Please share current and prior impact.*
How has xerostomia affected you or your loved one on the best and on worst days?*
Describe your best days and your worst days.
Are there specific activities that you can not do at all or as fully as you would like because of xerostomia?*
For Example: How does this affect relationships/friendships with others? How does it affect life activities (school/work, abilities, relationships, self-sufficiency, living situation, activities, etc.)? If you could do one activity that you currently are unable to, what would it be?
What are you or your loved one currently (or recently) doing to manage xerostomia symptoms?*
For Example: What, if any, treatment options help manage xerostomia? How has this treatment regime changed over time and why?
How well have these treatments affected the impact of your or your loved one's xerostomia?*
What are the most significant downsides to your or your loved one's xerostomia treatments and how do they affect daily life?*
Examples of downsides may include bothersome side effects, going to the hospital for treatment, etc.