by filling out the questionaire below and submitting it.
City or Town
State or Province
Please Check Ones You Have Had.
If you have had another symptom or symptoms not listed,
please list them in the "Other" field provided at the end of
Heart Complications Lack of Concentration
Memory Problems Shortness of Breath Neuropathy
Dizziness Depression Hair Loss Sleep Disturbance
Acid Reflux Allergies Bone Fractures
Weight Gain Weight Loss
Rheumatoid Arthritis Asthma Granuloma
Family Members With Autoimmune Conditions:
Treatments You Have Tried or Any Combination Of The
Hydrea Interferon Gleevec Prednisone Anti-IL5
You On Any Of These Other Medications?:
Inhalers Zantac Tylenol Celcept Flovent
Paxil Prozac Welbutrin Warfarin
You Have Regular Tests Of The Following?:
Echo Every 6 Months Lung Xray Every Year
Regular Monthly or More Frequent Blood Tests
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