Autoimmunity - American Autoimmune Related Diseases Association

American Autoimmune
Related Diseases Association

Online Autoimmune Survey

The American Autoimmune Related Diseases Association is conducting a survey to collect information on autoimmune diseases. We would like to ask you to participate and help us with this project. The information submitted will be used for statistical information. We will use the information to increase support for basic autoimmune research and public awareness of autoimmune diseases. If you are interested in helping with this project, fill in the form and submit it to us.

Your age:

Gender:

Female
Male

A.	Do you have an autoimmune disease?	Yes No
B.	Was the diagnosis confirmed by a second opinion?	Yes No
C.	If you answered yes to question A, please enter the name of the disease.

D.	If you have more than one autoimmune disease, please list them below.


E.	Do you have other first degree relatives (mother, father, sibling, aunt, uncle, grandparent, grandchild) with an autoimmune disease?	Yes No
F.	If you answered Yes to question E, please list the disease/s and relationship/s.

G.	Was it dificult to get a diagnosis?	Yes No
H.	How long have you been diagnosed?

I.	How long did it take to get a correct diagnosis?

J.	How many doctors did you see before you were correctly diagnosed?

K.	The doctor who made the correct diagnosis was a general practioner or specialist?	specialist general practitioner
L.	If you were incorrectly diagnosed initially, list what you were diagnosed with prior to receiving a correct diagnosis.

M.	Was it ever implied by a physician that your symptoms were in your head or that you were a chronic complainer or that you were too concerned about your health?	Yes No
N.	Would you be willing to be contacted if a researcher was interested in studing your family? If your answer is yes, please be sure to fill in the information below	Yes No

The following information is optional.
Name:
Street:
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State:	Zip:
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E-Mail:
Phone:

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