K
_Kim_
Guest
WPI Research Questionnaire is now online!
WPI Volunteer Questionnaire
All information you provide is personal and confidential.
Personal Information Last Name: First Name: Middle Initial:
Male Female
Date of Birth: / / (enter date as: MM/DD/YYYY)
Street Address:
City: State: Zip Code:
Country:
Home Phone: (enter phone as: XXX XXX-XXXX)
Work Phone: (enter phone as: XXX XXX-XXXX)
Cell Phone: (enter phone as: XXX XXX-XXXX)
Email:
Physician Information Last Name: First Name: Middle Initial:
National Provider Identifier (NPI):
Street Address:
City: State: Zip Code:
Country:
Office Phone: (enter phone as: XXX XXX-XXXX)
FAX: (enter FAX as: XXX XXX-XXXX)
Email:
Medical History ⇒ Primary Diagnosis (please check all that apply)
ME/CFS
Fibromyalgia
Multiple Sclerosis
Encephalopathy
Lupus or other auto-immune disease
Other, please describe:
Date of Onset: / / (enter date as: MM/DD/YYYY)
Date of Diagnosis: / / (enter date as: MM/DD/YYYY)
⇒ Initial Symptoms (please check all that apply)
Headache
Sore throat
Painful muscles
Painful joints
Fever
Rash
Gastrointestional disorders
Nerve pain
Disturbed balance
Profound weakness
Difficulty with short term memory
Difficulty with mental processing
Other, please describe:
⇒ Current Symptoms
Are you currently having any symptoms? Yes No
If you are currently having symptoms, please list below:
⇒ Current Medication
Are you currently taking any medication? Yes No
If you are currently taking medication, please list below:
⇒ Co-Infections
Do you have any co-infections? Yes No
If you have co-infections, please list them below:
⇒ Secondary Diagnosis (please check all that apply)
Asthma Cancer, please specify type:
Cardiovascular Disease Crohn's Disease
Diabetes Inflammatory Bowel Disease
Neurological Disease (Alzheimer's, Parkinson's),
please specify type:
Pulmonary Disease
⇒ Surgeries
Have you ever had any surgeries? Yes No
If you have had any surgeries, please list them below:
⇒ Blood Transfusions
Have you ever had a blood transfusion? Yes No
⇒ Adverse reactions to vaccinations
Have you ever had an adverse reaction to a vaccination? Yes No
⇒ Other complicating factors
Do you have any other complicating factors? Yes No
If you have had any other complicating factors, please list them below:
Family Members Health ⇒ Do any immediate family members have a neuro-immune or related disease such as prostate cancer, autism, etc.?
Yes No
Mother, please specify diseases and/or conditions:
Father, please specify diseases and/or conditions:
Brothers, please specify diseases and/or conditions:
Sisters, please specify diseases and/or conditions:
⇒ Do any children have health issues?
Yes No
Child 1, please specify diseases and/or conditions:
Child 2, please specify diseases and/or conditions:
Child 3, please specify diseases and/or conditions:
Child 4, please specify diseases and/or conditions:
Child 5, please specify diseases and/or conditions:
⇒ Would you like to be a part of the WPI research program by donating your blood sample to the WPI repository?
Yes No
Would you like to make a donation to support the WPI Research Program? Please see the "How to Help" tab on our homepage.
Thank you!
WPI Volunteer Questionnaire
All information you provide is personal and confidential.
Personal Information Last Name: First Name: Middle Initial:
Male Female
Date of Birth: / / (enter date as: MM/DD/YYYY)
Street Address:
City: State: Zip Code:
Country:
Home Phone: (enter phone as: XXX XXX-XXXX)
Work Phone: (enter phone as: XXX XXX-XXXX)
Cell Phone: (enter phone as: XXX XXX-XXXX)
Email:
Physician Information Last Name: First Name: Middle Initial:
National Provider Identifier (NPI):
Street Address:
City: State: Zip Code:
Country:
Office Phone: (enter phone as: XXX XXX-XXXX)
FAX: (enter FAX as: XXX XXX-XXXX)
Email:
Medical History ⇒ Primary Diagnosis (please check all that apply)
ME/CFS
Fibromyalgia
Multiple Sclerosis
Encephalopathy
Lupus or other auto-immune disease
Other, please describe:
Date of Onset: / / (enter date as: MM/DD/YYYY)
Date of Diagnosis: / / (enter date as: MM/DD/YYYY)
⇒ Initial Symptoms (please check all that apply)
Headache
Sore throat
Painful muscles
Painful joints
Fever
Rash
Gastrointestional disorders
Nerve pain
Disturbed balance
Profound weakness
Difficulty with short term memory
Difficulty with mental processing
Other, please describe:
⇒ Current Symptoms
Are you currently having any symptoms? Yes No
If you are currently having symptoms, please list below:
⇒ Current Medication
Are you currently taking any medication? Yes No
If you are currently taking medication, please list below:
⇒ Co-Infections
Do you have any co-infections? Yes No
If you have co-infections, please list them below:
⇒ Secondary Diagnosis (please check all that apply)
Asthma Cancer, please specify type:
Cardiovascular Disease Crohn's Disease
Diabetes Inflammatory Bowel Disease
Neurological Disease (Alzheimer's, Parkinson's),
please specify type:
Pulmonary Disease
⇒ Surgeries
Have you ever had any surgeries? Yes No
If you have had any surgeries, please list them below:
⇒ Blood Transfusions
Have you ever had a blood transfusion? Yes No
⇒ Adverse reactions to vaccinations
Have you ever had an adverse reaction to a vaccination? Yes No
⇒ Other complicating factors
Do you have any other complicating factors? Yes No
If you have had any other complicating factors, please list them below:
Family Members Health ⇒ Do any immediate family members have a neuro-immune or related disease such as prostate cancer, autism, etc.?
Yes No
Mother, please specify diseases and/or conditions:
Father, please specify diseases and/or conditions:
Brothers, please specify diseases and/or conditions:
Sisters, please specify diseases and/or conditions:
⇒ Do any children have health issues?
Yes No
Child 1, please specify diseases and/or conditions:
Child 2, please specify diseases and/or conditions:
Child 3, please specify diseases and/or conditions:
Child 4, please specify diseases and/or conditions:
Child 5, please specify diseases and/or conditions:
⇒ Would you like to be a part of the WPI research program by donating your blood sample to the WPI repository?
Yes No
Would you like to make a donation to support the WPI Research Program? Please see the "How to Help" tab on our homepage.
Thank you!
