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WPI Volunteer Questionnaire

All information you provide is personal and confidential.


Personal Information Last Name: First Name: Middle Initial:

Male Female

Date of Birth: / / (enter date as: MM/DD/YYYY)

Street Address:
City: State: Zip Code:
Country:

Home Phone: (enter phone as: XXX XXX-XXXX)
Work Phone: (enter phone as: XXX XXX-XXXX)
Cell Phone: (enter phone as: XXX XXX-XXXX)
Email:

Physician Information Last Name: First Name: Middle Initial:
National Provider Identifier (NPI):
Street Address:
City: State: Zip Code:
Country:

Office Phone: (enter phone as: XXX XXX-XXXX)
FAX: (enter FAX as: XXX XXX-XXXX)
Email:

Medical History ⇒ Primary Diagnosis (please check all that apply)
ME/CFS
   Fibromyalgia
Multiple Sclerosis
   Encephalopathy
Lupus or other auto-immune disease
   Other, please describe:
Date of Onset: / / (enter date as: MM/DD/YYYY)
Date of Diagnosis: / / (enter date as: MM/DD/YYYY)

⇒ Initial Symptoms (please check all that apply)
Headache
   Sore throat
Painful muscles
   Painful joints
Fever
   Rash
Gastrointestional disorders
   Nerve pain
Disturbed balance
   Profound weakness
Difficulty with short term memory
   Difficulty with mental processing
Other, please describe:
    

⇒ Current Symptoms
Are you currently having any symptoms? Yes No
If you are currently having symptoms, please list below:


⇒ Current Medication
Are you currently taking any medication? Yes No
If you are currently taking medication, please list below:


⇒ Co-Infections
Do you have any co-infections? Yes No
If you have co-infections, please list them below:


⇒ Secondary Diagnosis (please check all that apply)
Asthma   Cancer, please specify type:
Cardiovascular Disease   Crohn's Disease
Diabetes   Inflammatory Bowel Disease
Neurological Disease (Alzheimer's, Parkinson's),
  please specify type:
  Pulmonary Disease

⇒ Surgeries
Have you ever had any surgeries? Yes No
If you have had any surgeries, please list them below:


⇒ Blood Transfusions
Have you ever had a blood transfusion? Yes No

⇒ Adverse reactions to vaccinations
Have you ever had an adverse reaction to a vaccination? Yes No

⇒ Other complicating factors
Do you have any other complicating factors? Yes No
If you have had any other complicating factors, please list them below:


⇒ XMRV Testing
Have you been tested for XMRV? Yes No
If "Yes", what was the result? Positive Negative
Which laboratory performed the test? (please list below)

Family Members Health ⇒ Do any immediate family members have a neuro-immune or related disease such as prostate cancer, autism, etc.?
Yes No
Mother, please specify diseases and/or conditions:
Father, please specify diseases and/or conditions:
Brothers, please specify diseases and/or conditions:
Sisters, please specify diseases and/or conditions:

⇒ Do any children have health issues?
Yes No
Child 1, please specify diseases and/or conditions:
Child 2, please specify diseases and/or conditions:
Child 3, please specify diseases and/or conditions:
Child 4, please specify diseases and/or conditions:
Child 5, please specify diseases and/or conditions:

⇒ Would you like to be a part of the WPI research program by donating your blood sample to the WPI repository?
Yes No

Note: If you wish to save a copy of this form for your records, you must print it before you submit the form to WPI.


Would you like to make a donation to support the WPI Research Program? Please see the "Get Involved" tab on our homepage.

Thank you!