Re: Questionnaire

Doc (doc09(AT)sprintmail.com)
Sat, 29 Aug 1998 03:32:10 -0400

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Hello all:
Just a reminder and request for each of
you to complete the questionnaire.
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.
=20
1. GENDER:
=20
2. DATE OF Dx: LOCATION: (City,State)
=20
AGE AT Dx: LOCATION: (City, State)
=20
CURRENT AGE: LOCATION: (City, State)
=20
BIRTH LOCATION:(City,State)
=20
UNUSUAL CIRCUMSTANCES: (Lived one place Dx'd in another =
location..
(There were a couple of you who were on vacation or business).
=20
=20
3. CURRENT MEDICATIONS: (Please List)
=20
=20
4. MEDICATIONS TRIED BUT DID NOT WORK FOR YOU.(Please List)
=20
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:
=20
NAME:
SPECIALTY:
HOSPITAL AFFILIATION:
CITY, STATE
TELEPHONE:
=20
6. IF YOU HAVE BEEN TREATED BY A PHYSICIAN/NEUROLOGIST
THAT SHOULD BE AVOIDED AT ALL COSTS BY THOSE WITH
TM:
=20
NAME:
SPECIALTY:
HOSPITAL AFFILIATION:
CITY, STATE
=20
I hope this information will aide many.
=20
=20
=20
Doc
=20
=20
=20

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD W3 HTML//EN">
Hello=20 all: Just=20 a reminder and request for each of you=20 to complete the questionnaire. As=20 I promised in my previous note, I will collate this data and
I = will not=20 release any of it on any individual unless given
permission. The=20 geography questions are related to MS
research. I would ask that=20 everyone, including lurkers, just
readers and visitors, to = complete the=20 questionnaire if it applies to
you, a family member or friend = with a Dx=20 of Transverse
Myelitis (TM). Hopefully we can make a=20 difference.

1. GENDER:

2. DATE OF=20 = Dx:           &nbs= p;            = ; =20 LOCATION: (City,State)

   AGE AT=20 = Dx:           &nbs= p;            = ;   =20 LOCATION: (City, State)

   CURRENT=20 = AGE:           &nb= sp;       =20 LOCATION: (City, State)

   BIRTH=20 LOCATION:(City,State)

   UNUSUAL CIRCUMSTANCES: = (Lived one=20 place Dx'd in another location..
     (There = were a=20 couple of you who were on vacation or business).


3. = CURRENT=20 MEDICATIONS: (Please List)


4. MEDICATIONS TRIED BUT DID = NOT WORK=20 FOR YOU.(Please List)

5. IF YOU FEEL THAT YOUR = PHYSICIAN/NEUROLOGIST=20 IS
    EXPERIENCED WITH TM (or atleast willing to = learn)=20 PLEASE
    LIST HIM AS SOMEONE YOU WOULD RECOMMEND = TO=20 OTHER:

       =20 NAME:
       =20 SPECIALTY:
        HOSPITAL=20 AFFILIATION:
        CITY,=20 STATE
        = TELEPHONE:

6. IF=20 YOU HAVE BEEN TREATED BY A = PHYSICIAN/NEUROLOGIST
    THAT=20 SHOULD BE AVOIDED AT ALL COSTS BY THOSE WITH
   =20 TM:

        =20 NAME:
        =20 SPECIALTY:
         = HOSPITAL=20 AFFILIATION:
         = CITY,=20 STATE

I hope this information will aide = many.

  Doc



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