Full Name:  * Address (Optional): City & State  * Email Address:  * Home Phone #  * Cell / Work Phone (Optional) Name & Age of person with SJS / TENS  * What were you diagnosed with? Stevens Johnson Syndrome (SJS) Toxic Epidermal Necrolysis Syndrome (TENS) Lyell's Syndrome Other Date that SJS type symptoms first appeared (Approximate)  * Date you were diagnosed with SJS or TENS ? (Approximate)  * Select State in which you were diagnosed: State of Diagnosis:Alabama - ALAlaska - AKArizona - AZArkansas - ARCalifornia - CAColorado - COConnecticut - CTDelaware - DEFlorida - FLGeorgia - GAHawaii - HIIdaho - IDIllinois - ILIndiana - INIowa - IAKansas - KSKentucky - KYLouisiana - LAMaine - MEMaryland - MDMassachusetts - MAMichigan - MIMinnesota - MNMississippi - MSMissouri - MOMontana - MTNebraska - NENevada - NVNew Hampshire - NHNew Jersey - NJNew Mexico - NMNew York - NYNorth Carolina - NCNorth Dakota - NDOhio - OHOklahoma - OKOregon - ORPennsylvania - PARhode Island - RISouth Carolina - SCSouth Dakota - SDTennessee - TNTexas - TXUtah - UTVermont - VTVirginia - VAWashington - WAWest Virginia - WVWisconsin - WIWyoming - WYOUTSIDE OF USA............................................................................US Name of Drug you believe caused your SJS or TENS:  * Which drug(s) were taken in the last 7 days before first symptoms appeared: Dilantin (phenytoin) Dilantin (Generic) Tegretol (carbamazepine) Tegretol (Generic) Levaquin (levofloxacin) Levaquin (Generic) Parts of your body effected and description of injuries:  * Have you been hospitalized or had surgeries due to SJS or TENS? Please give details.  * Comments or questions that you have:  * Do not enter anything in this field: