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 select the name of the disease from the drop down list below:

D. If you have more than one autoimmune disease, please select up to five 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 select up to four (4) first degree relatives and select the autoimmune disease associated with that first degree relative.
Relationship

Parent Sibling Child Grandparent Grandchild Aunt or Uncle

Select Disease:

Relationship
Parent Sibling Child Grandparent Grandchild Aunt or Uncle Select Disease:
Relationship
Parent Sibling Child Grandparent Grandchild Aunt or Uncle
Select Disease:
Relationship
Parent Sibling Child Grandparent Grandchild Aunt or Uncle Select Disease:
G. Was it difficult to get a diagnosis? Yes No
H. How long have you been diagnosed?
Enter a numeral to indicate the number of years. If less than one year, enter a decimal point followed by the number of months.
I. How long did it take to get a correct diagnosis?
Enter a numeral to indicate the number of years. If less than one year, enter a decimal point followed by the number of months.
J. How many doctors did you see before you were correctly diagnosed? Please enter a numeral.
K. The doctor who made the correct diagnosis was a general practitioner or specialist? SpecialistGeneral 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 studying your family? If your answer is yes, please be sure to fill in the information below Yes No
Please enter your state and/or country below.
Name, street, city, phone, and zip code information are optional.
Name:
Street:
City:
State:   Zip Code:
Country :
Phone:
Email: .
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