Please help us gather information on HES
by filling out the questionaire below and submitting it.


AGE Person first discovered had HES:
YEAR Person first discovered had HES:
BIRTHDAY /Year:
SEX of person with HES: Female Male

Location:
City or Town
State or Province
Country

SYMPTOMS of HES
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
this list.

Fatigue Hives GI Problems Asthma
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
Other

Other Autoimmune Conditions:
Rheumatoid Arthritis Asthma Granuloma

Other Family Members With Autoimmune Conditions:
Relation Condition
Relation Condition

Medical Treatments You Have Tried or Any Combination Of The Following:
Hydrea Interferon Gleevec Prednisone Anti-IL5
Other Treatments

Are You On Any Of These Other Medications?:
Inhalers Zantac Tylenol Celcept Flovent
Paxil Prozac Welbutrin Warfarin
Other

Other Organs Affected:
Thyroid
Other

Do You Have Regular Tests Of The Following?:
Echo Every 6 Months Lung Xray Every Year
Regular Monthly or More Frequent Blood Tests
Other

CHECK Out Our Support Group


ALSO
The American Partnership
for Eosinophilic Disorders
is a non-profit advocacy organization for those living with eosinophilic esophagitis, eosinophilic gastroenteritis, eosinophilic colitis, hypereosinophilic syndrome, and other eosinophilic disorders.

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