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1 Alopecia Areata Registry: Short Form Questionnaire: Date of Revision: June 2010 Page 1 of 5 This questionnaire is only for people who live in the U.S.A and who have personal or family documentation of Alopecia Areata or Alopecia Totalis or Alopecia Universalis by a Dermatologist ALOPECIA AREATA Registry and Family Study I have read the description of the study, and I have decided to participate in the research project described here. I understand that I may refuse to answer any (or all) of the questions at this or any other time. I understand that there is a possibility that I might be contacted in the future about this, but that I am free to refuse any further participation if I wish. Please fill in all the blanks or check the appropriate boxes, the starred fields (*) are optional: Last Name (Registrant): Date: / / First Name: Middle Maiden Primary Contact Address: City/State/Zip Code: Telephone Number: (Home) (Work) * FAX: * If you have alopecia, has a dermatologist ever diagnosed or confirmed your alopecia areata? Yes If yes, Your Dermatologist s Name Phone # Your Dermatologist s Address Other Doctors: Doctor s Name: MR#: Doctor saddress: Street City State Zip Country Specialty: Fax: Tel # Doctor s Name: MR#: Doctor saddress: Street City State Zip Country Specialty: Fax: Tel # I am registering as a CONTROL, unaffected person not blood-related to anyone with AA: Yes Biological Mother s Name: Last First Maiden Is she alive? /Unknown Yes Phone # Biological Father s Name: Is he alive? /Unknown Yes Phone # I am filling this form out for Myself My child Other: (My spouse, my friend, my patient, etc. ) If you are filling this out for someone else, please give your name: If someone in your family with AA has already registered please give his/her name and contact information so that the computer can connect relatives. Everyone in the family should list the same family AA person even if there are multiple family members who have AA. Please identify how you are
2 Alopecia Areata Registry: Short Form Questionnaire: Date of Revision: June 2010 Page 2 of 5 related to this family AA person (father, aunt, cousin) AND whether you are related on the maternal (mother s) or paternal (father s) side of the family. My spouse or significant other has AA Other Yes, I am related to proband by blood and my relationship to him/her is: Myself Brother Sister Identical twin Fraternal twin Mother Father Uncle Aunt Cousin Parents of mother Parents of father Other Name: I am this person s: Telephone Number: (Primary) (Secondary) FAX: Primary Contact Address: The following information is required (unless starred) to participate in the Registry: 1. Sex: Male Female 2. Date of Birth: / / 3. Are you adopted? Yes 4. * What is your current marital status? (Check one) Never married Widowed Separated Divorced Married Number of times. 5. *Race: American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian/Other Pacific Islander White Mixed Race: Other: 6. My natural hair color is: Red Blonde Brown Auburn Black Gray White Other: 7. Are you a Twin? or Yes: Fraternal Identical Unknown type Triplets or more 8. HAVE YOU EVER HAD AT ANY TIME IN YOUR LIFE PATCHY ALOPECIA AREATA (AA), TOTALIS (AT) OR UNIVERSALIS (AU)? go to question 17 Yes -(continue) 9. Age of first onset of AA/AT/AU: Under 6 months of age at onset? or Yes 10. Did you ever have a biopsy of your scalp? Yes 11. The greatest amount of hair loss ever experienced on your scalp is ne Up to 25% 26-50% 51-75% 76-99% 100% (completely bald) 12. Did this episode last for less than 6 months 6 months-1 year 1-2 years greater than 2 years? 13. Have you lost body hair? or Yes Some hair, All hair 14. Are nails involved? or Yes Some nails All nails 15. How many episodes of AA/AT/AU have you had? Only 1(Including Continuous) more than 10 Too many to count Don t know 16. Was there an environmental trigger, an event/exposure, or an infection within 6 months of the first episode? or Yes, explain: ******* Do you have seasonal flares of AA? Yes Spring Summer Fall Winter 17. Has anyone in your family, not including yourself, ever had patchy AA/AT or AU?, go to question #19. Or Yes Are they related by marriage Yes Spouse Stepchild Other Are they related by blood? or Yes Number of living blood relatives with AA in family (NOT INCLUDING YOU) is:. Number of living brothers with AA is. Number of living sisters with AA is:. If you have other living blood relatives with AA, check any that apply. _
3 Alopecia Areata Registry: Short Form Questionnaire: Date of Revision: June 2010 Page 3 of 5 Mother Parents of mother Uncle(s)(mother's side) Aunt(s)(mother's side) Cousin(s)(mother's side) Father Parents of father Uncle(s)(father's side) Aunt(s)(father's side) Cousin(s)(father's side) Identical twin Fraternal twin Son Daughter Grandson Granddaughter Multiple children Other (please indicate mother s side versus father s side of the family): Number of dead blood relatives with AA in family is:. If you have dead blood relatives with AA, list the relationships of these people to you (mother s versus father s side of the family): 18. If your brother(s) or sister(s) have AA/AT/AU, what kind(s) of alopecia do they have? AA AT AU Do you have living family members with AA/AT/AU that are not your brother(s) or sister(s)? Yes 19. Are you interested in future research on treatments or other research studies, and would you wish to be informed about these studies by Registry personnel? 20. Are you willing to have blood drawn for research either as AA patient, family member or control? Yes 21. Are you willing to participate in the Second Tier at any of the following sites? or Yes Check all that apply Houston New York Denver Minneapolis San Francisco Private (Local )MD Note: The Registry is unable to pay for travel 22. Have you had blood drawn for HLA in past? or Yes 23. Have you participated in any alopecia research study in the past? or Yes
4 Alopecia Areata Registry: Short Form Questionnaire: Date of Revision: June 2010 Page 4 of Do you have any of the allergic, rheumatic, collagen vascular, or autoimmune diseases listed below? go to end of last page. Yes Please check all that apply and give an approximate age of onset: Addison s disease ALLERGIES Asthma Atopic dermatitis or eczema Hay fever/allergic rhinitis Urticaria (hives) or angioedema Other allergies Allergy shots ARTHRITIS Ankylosing spondylitis Spondyloarthritis Juvenile arthritis Reiter s syndrome Rheumatoid arthritis Other forms of arthritis COLLAGEN VASCULAR DIS. Antiphospholipid syndrome (Anticardiolipin syndrome) Fibromyalgia-fibromyositis Polymyositis/dermatomyositis Raynaud s syndrome CREST syndrome Scleroderma Sjogren s syndrome Systemic lupus erythematosus (Lupus, SLE) Specify Type and age of onset: Time period: From (Year) To (Year) Allergy Shots For: Specify Type: Autoimmune polyendocrinopathycandidosis-ectodermal dystrophy (APS1 = autoimmune polyendocrine syndrome type1) Autoimmune hemolytic anemia Autoimmune hepatitis (noninfectious chronic active hepatitis) Behcet s disease AUTOIMMUNE BLISTERING DIS. Bullous pemphigoid Cicatrical pemphigoid Dermatitis herpetiformis Type: Pemphigus vulgaris Type: Cardiomyopathy Celiac disease/sprue Diabetes Type of diabetes : Insulin dependent diabetes mellitus (Type I, juvenile diabetes); n-insulin dependent diabetes mellitus (Type II, adult onset) Unknown; Other: Type of Treatment: ( all that apply) Pills Diet Insulin treatment Idiopathic thrombocytopenic purpura (ITP) Inflammatory bowel disease Clinical Depression ADHD Bipolar Disease Type: Crohn s disease, Ulcerative colitis, Irritable bowel syndrome
5 Alopecia Areata Registry: Short Form Questionnaire: Date of Revision: June 2010 Page 5 of 5 Kidney disease Type of Kidney disease: IgA nephropathy, Glomerulonephritis, Nephrosis, Nephrotic syndrome; Other Lichen planus NEUROLOGICAL DISEASE Chronic inflammatory demyelinating polyneuropathy Guillain-Barré syndrome Multiple sclerosis Myasthenia gravis Pernicious anemia Polychondritis Primary biliary cirrhosis Psoriasis Rheumatic fever Sarcoidosis Schmidt syndrome (APS2 = autoimmune polyendocrine syndrome type2) Stiff-man syndrome (Moersch-Woltmann syndrome) Thyroid disease 1.) Age of onset: Do you take thyroid replacement? 2.) Type of thyroid disease: Graves disease; Myxedema; Hyperthyroidism; Hashimoto s thyroiditis; Goiter; Hypothyroidism; Other Uveitis VASCULITIS Churg-Strass syndrome (Allergic granulomatosis) Cold agglutinin disease Essential mixed cryoglobulinemia Polyarteritis nodosa Polymyalgia rheumatica Takayasu arteritis Temporal arteritis (Giant cell arteritis) Vitiligo Extent of Vitiligo Waardenburg syndrome Congenital: no date of onset 25. Do any of your relatives have any of the above diseases? or Yes Please list 1) the diseases, 2) the relationships of these people to you, and 3) whether they are on your mother s side or father s side of the family: Thank you for participating in the initial questionnaire for the Alopecia Areata Registry. We will contact you again after we review your information. You may withdraw from the Registry at any time. You can contact us and mail, fax, or your forms and questions to: Alopecia Areata Registry M. D. Anderson Cancer Center Department of Dermatology Box Pressler Street, Houston, Texas Tel: Fax: alopeciaregistry@mdanderson.org Website:
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NEW PATIENT HEALTH HISTORY
Meeks and Zilberfarb Orthopedics 1101 Beacon Street. Brookline, MA 02246 40 Allied Drive, Dedham, MA 02026 Tel: 617-232-2663 Fax: 617-232-6342 Tel:781-326-1561 Fax:781-326-1562 Jeffrey L. Zilberfarb, MD
INFORMED CONSENT FOR ANORECTAL PROCEDURES
516-248-2422 www.crssny.com Locations in Nassau, Suffolk and Queens INFORMED CONSENT FOR ANORECTAL PROCEDURES You may undergo anoscopy or proctosigmoidoscopy as part of your rectal examination. These tests
Water Supply: City Well
Endocrine Information Sheet Please complete this endocrine information sheet and bring to your child s appointment. Date: Child s Name: Date of Birth: Age: Race/Sex Address: City: State: Zip Code: Home
Today s Date: Pt Initials: PATIENT INFORMATION. First Name: Last Name: Middle Name: Date of Birth: Social Security #: Preferred Language:
PATIENT INFORMATION First Name: Last Name: Middle Name: Suffix: Nickname: Male Female Date of Birth: Social Security #: Preferred Language: Race: Asian Native Hawaiian Other Pacific Islander Black / African
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
The Changing Face of Celiac Disease. John Snyder, MD
The Changing Face of Celiac Disease John Snyder, MD OVERVIEW Brief Background on the Basics Changing Face 1. Autoimmune Nature and Impact 2. Diagnosis Does everyone need a biopsy? Should genetic testing
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Reason for visit: Previous and/or Maiden Name: Parent/Guardian Name if patient is minor: Birth date: (M/D/Yr) Gender: Male Female SSN (patient): SSN (guardian, if patient is minor):
The Changing Face of Celiac Disease. John Snyder, MD
The Changing Face of Celiac Disease John Snyder, MD Special Thanks Blair and Steve Raber, founders of the Children s National Celiac Disease Program Rhonda and Peter Resnick, for providing a generous gift
Patient Interview Form
Page 1 of 5 Gastroenterologists: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Samuel J. Tarwater, MD Travis J. Rutland, MD Gastroenterologists: Marc L.
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
Psychiatric Evaluation Intake Form
Psychiatric Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
Center for Reproductive Medicine Advanced Reproductive Technologies
Center for Reproductive Medicine Advanced Reproductive Technologies www.ivfminnesota.com New Patient Questionnaire Name DOB Age Marital Status: Single Married Partnered Separated Divorced Remarried Occupation
New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
PATIENT INFORMATION. (Last) (First) (Middle) (Last) (City) (State) (Zip)
PATIENT INFMATION : Address: (Last) (First) (Middle) (Last) (City) (State) (Zip) Home Phone: Cell Phone: Email address: Birth date: : Gender: When is the best time to contact you? May we email you for
Egg Donor screening Questionnaire. How many years did you complete in high school?
Please tick ( ) and complete ALL questions. YOU YOUR PARTNER Full name Forename Surname Forename Surname Date of birth day / month / year day / month / year Address Height : Weight: Ethnicity Home Tel: