Hello all:
I have only received about a dozen
reponses to the Questionnaire. Please
take a minute and respond.
Thanks
Doc
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Message-ID: <35D205E7.5C4DC45C(AT)sprintmail.com>
Date: Wed, 12 Aug 1998 17:15:19 -0400
From: Doc <doc09(AT)sprintmail.com>
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To: TMIC <tmic-list(AT)eskimo.com>
Subject: QUESTIONNAIRE
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As I promised in my previous note, I will collate this data and
I will not release any of it on any individual unless given
permission. The geography questions are related to MS
research. I would ask that everyone, including lurkers, just
readers and visitors, to complete the questionnaire if it applies to
you, a family member or friend with a Dx of Transverse
Myelitis (TM). Hopefully we can make a difference.
1. GENDER:
2. DATE OF Dx: LOCATION: (City,State)
AGE AT Dx: LOCATION: (City, State)
CURRENT AGE: LOCATION: (City, State)
BIRTH LOCATION:(City,State)
UNUSUAL CIRCUMSTANCES: (Lived one place Dx'd in another location..
(There were a couple of you who were on vacation or business).
3. CURRENT MEDICATIONS: (Please List)
4. MEDICATIONS TRIED BUT DID NOT WORK FOR YOU.(Please List)
5. IF YOU FEEL THAT YOUR PHYSICIAN/NEUROLOGIST IS
EXPERIENCED WITH TM (or atleast willing to learn) PLEASE
LIST HIM AS SOMEONE YOU WOULD RECOMMEND TO OTHER:
NAME:
SPECIALTY:
HOSPITAL AFFILIATION:
CITY, STATE
TELEPHONE:
6. IF YOU HAVE BEEN TREATED BY A PHYSICIAN/NEUROLOGIST
THAT SHOULD BE AVOIDED AT ALL COSTS BY THOSE WITH
TM:
NAME:
SPECIALTY:
HOSPITAL AFFILIATION:
CITY, STATE
I hope this information will aide many.
Doc
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