You can enter as much, or as little detail as you like. There are some personal questions - you do not have to answer these, it's your choice. They are there so that I can look for connections between sufferers. If you need any help, or advice on how to use this form, please contact me and I will be pleased to assist. When you have finished, click the 'Send Form' button at the bottom of the page.
All fields are optional Please scan through the form before you fill it in, as there may be questions that require a little research, such as Blood Type, Cholesterol Levels, etc.
About You Please try and enter as much detail as possible - It will help identify any common connections between sufferers.
Name: This for reference only, and will not be published in the results. Use an alias, if you prefer.
Email Address: This for reference only, and will not be published in the results.
Gender: Male Female - Select From List -
Age:
Height:
Weight:
Smoker? No Yes - Select From List - If yes, number per day:
Have you ever smoked? No Yes - Select From List -
Units of alcohol consumed per week: Please enter 'None' if non drinker
Do you have any Amalgam fillings? Some Lots None Don't Know - Select From List -
Do you partake in regular excercise/sport? Occasional Regular Light Regular Physical None - Select From List -
Have you ever suffered from stress? No Yes Diagnosed By Doctor - Select From List -
No. of hours per week spent at a computer
Location:
Is it a Town City Rural/Countyside Other - Select From List - If 'Other' please give bfief detail in 'Location' box
Country:
Nationality:
Roots - Mothers Side African American Australasian European Indian Other - Select From List - If 'Other', please state:
Roots - Fathers Side African American Australasian European Indian Other - Select From List - If 'Other', please state:
Your Employment History This is to establish if there are any common exposures in the workplace.
Notes: Education, management, or other office positions should be counted as 'Clerical/Computing. Only include in 'Transport' if you have been exposed to the working environment.
Current Employment Clerical/Computing Building Trade Manufacturing/Industrial Transport Retail Other - Select From List - If 'Other', please state
Current Employment Exposures Hazardous Chemicals Fuels (Petrol/Diesel etc.) Radiation Smoke/Dust Solvents Other None - Select From List - If 'Other', please state
Previous Employment Clerical/Computing Building Trade Manufacturing/Industrial Transport Retail Other - Select From List - If 'Other', please state
Previous Employment Exposures Hazardous Chemicals Fuels (Petrol/Diesel etc.) Radiation Smoke/Dust Solvents Other None - Select From List - If 'Other', please state
Any other Employment Clerical/Computing Building Trade Manufacturing/Industrial Transport Retail Other - Select From List - If 'Other', please state
Other Employment Exposures Hazardous Chemicals Fuels (Petrol/Diesel etc.) Radiation Smoke/Dust Solvents Other None - Select From List - If 'Other', please state
Any non work related exposures Hazardous Chemicals Fuels (Petrol/Diesel etc.) Radiation Smoke/Dust Solvents Other None - Select From List - If 'Other', please state
Please use this box to add any details of exposures that you feel relevant.
Your Condition Including medication, side effects, and blood details.
Name of Condition:
Date of Diagnosis:
Discovered following: Routine Medical/Blood Test Blood test due to other illness Problems caused by Thrombocythaemia Other - Select From List - Not Sure If 'Other', please state
Primary Symptoms: Headaches Blood Clots Irregular Heartbeat Poor Circulation Other None - Select From List - If 'Other', please state
Secondary Symptoms: Fatigue Joint/Bone Pain Skin Problems Internal Organ Problems Other None - Select From List - If 'Other', please state
Please use this box to add any details of symptoms that you feel relevant.
Current Medication: Only include medication prescribed for Thrombocythaemia (inc. Aspirin)
Main Current Medication Side Effects: Nausea/Diahrrea Hypertension Skin Rashes Heart Irregularities Fatigue/Pain Other None - Select From List - If 'Other', please state
Other Current Medication Side Effects: Nausea/Diahrrea Hypertension Skin Rashes Heart Irregularities Fatigue/Pain Other None - Select From List - If 'Other', please state
Past Medication:
Main Past Medication Side Effects: Nausea/Diahrrea Hypertension Skin Rashes Heart Irregularities Fatigue/Pain Other None - Select From List - If 'Other', please state
Other Past Medication Side Effects: Nausea/Diahrrea Hypertension Skin Rashes Heart Irregularities Fatigue/Pain Other None - Select From List - If 'Other', please state
Initial Platelet Count:
Current Platelet Count:
Highest Platelet Count:
Any related illnesses or medical problems? Sinus Problems Heart Attack Stroke Leaukaemia Leiden Factor V Other None - Select From List - If 'Other', please state
Any other illnesses or medical problems? Arthritis Thyroid Problems Asthma Diabetes Other None - Select From List - If 'Other', please state
Any Allergies Penecillin Nut Hayfever/Seasonal Gluten Other None Don't Know - Select From List - If 'Other', please state
Blood Group: A B AB O Don't Know - Select From List - Rhesus Factor Negative Positive Don't Know - Select From List -
Cholesterol Level (mmol/L): Low (Less than 4) Normal (4-7.1) High (Greater than 7.1) Don't Know - Select From List - To convert a cholesterol measurement in mg/dL to mmol/L you divide by 39.
JAK2 Gene? Positive Negative Don't Know - Select From List - (You will only know this if you have had a specific test for this mutation)
Other Stuff
Please list any family history of blood disorders, heart attack, or stroke
Have you tried any alternative/natural remedies Yes No - Select From List -
If yes, please give details, and state if any success was achieved:
Please use the following space to add any details you consider relevant.
THANK YOU FOR YOUR SUPPORT
If there are any possible root cause/trigger factors that you think should be included in this survey, please let me know using the contact page.
Please review your answers before sending this form. Go back to beginning. Only click the 'Reset' button if you wish to start from scratch. Individual answers can be changed as required.
Careful - This clears all data from the form.
Sends the data - You might want to review the form before clicking this button.
See the MEJ Thrombocythaemia Discussion Forum
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