<<Disclaimer: Verify this information before applying it to your situation.>>
Dear subscribers,
I am a doctor-immunologist from Kazakhstan. I collect information
about the immunity and the digestive system. I would be very grateful to
everyone for answering the questions listed below. This information
will be processed by a computer and I will let you know the results.
It is interesting for me to compare CD patients with the patients
having other intestinal problems.
My address: immun!root@scoutnet
In SUBJECT, please, note QUESTIONS
Thank you very much,
Michail Valivach, MD
Questions
1. Name (or pseudonym):
2. Birth date:
Stature:
Weight:
Sex:
3. How long have you been GF?
4. Do you have chronic (lasting more than 2 months) of frequent (more
than 4 episodes in a year) infectious and noninfectious inflammatory diseases?
Yes, No, I can not answer
If "No" go to the item 5.
If "Yes", please answer the following questions:
a. Do you have chronic or frequent respiratory infections?
Yes, No, I can not answer
If so, are you easily infected during epidemics
Yes, No, I can not answer
and/or you have your own chronic or relapsing infection
(for instance, chronic bronchitis, tonsillitis etc)
Yes, No, I can not answer
List the infections:
b. Do you have or had asthma?
Yes, No, I can not answer
5. Do you have any skin diseases?
Yes, No, I can not answer
If "Yes", please, list their diagnoses:
6. Are you predisposed to allergic reactions?
Yes, No, I can not answer
If "Yes", please, give more information
7. Do you have any diseases of the digestive system (additionally
to CD)?
Yes, No, I can not answer
Please, list them:
9. The highest body temperature during the last 3 years:
10. Are you predisposed to long lasting (more than 14 days) fever?
Yes, No, I can not answer
11. Fatigue
12. Please, describe you skin. Do you have:
a. Constant or episodic hair loss
Yes, No, I can not answer
b. Dry or tarnished hair
Yes, No, I can not answer
c. Early turning gray (before 30)
Yes, No, I can not answer
d. Predisposition to dandruff
Yes, No, I can not answer
e. Fragility of the nail walls
Yes, No, I can not answer
f. Fragility of the nails
Yes, No, I can not answer
g. Dryness of the lips
Yes, No, I can not answer
h. Cyanosis of the lips
Yes, No, I can not answer
i. General skin dryness
Yes, No, I can not answer
j. Dryness and/or scaling and/or irritation
- in the nasolabial region
Yes, No, I can not answer
- of the elbows and/or knees
Yes, No, I can not answer
- above the brows (including dandruff) and/or around the eyes
Yes, No, I can not answer
- of the hands (especially after water exposure)
Yes, No, I can not answer
- of the cheeks
Yes, No, I can not answer
- of the nose
Yes, No, I can not answer
- of the ears
Yes, No, I can not answer
k. Follicular hyperkeratosis (perifollicular accentuation). That
means small dry skin elevations around the hair follicles.
Yes, No, I can not answer
l. Cyanotic, marbled skin
Yes, No, I can not answer
m. Scaling dermatitis (like eczema)
Yes, No, I can not answer
n. Red spots with dryness and/or scaling and/or irritation
Yes, No, I can not answer
o. Predisposition to acne (black heads)
Yes, No, I can not answer
p. Bad tolerance to sun burns
Yes, No, I can not answer
q. Skin itching
Yes, No, I can not answer
r. Chronic skin candidiasis (yeast infection)
Yes, No, I can not answer
s. Feet cyanosis
Yes, No, I can not answer
t. Patch-shaped foci of hyperkeratosis (foci of dry and thick skin)
Yes, No, I can not answer
13. Please, describe the tongue:
a. Enlarged tongue with the teeth imprints
Yes, No, I can not answer
b. Smooth ("polish") tongue
Yes, No, I can not answer
c. Hypertrophy of the tongue papillae (small round elevations)
Yes, No, I can not answer
d. Dry bright-red tongue
Yes, No, I can not answer
e. Cracks or folds on the tongue
Yes, No, I can not answer
f. Irritation and/or brown cover of the tongue base
Yes, No, I can not answer
g. Dryness of the mucous membranes
Yes, No, I can not answer
h. Gum bleeding after teeth brushing
Yes, No, I can not answer
14. Gastrointestinal tract:
a. Unpleasant smell from the mouth
Yes, No, I can not answer
b. Pains in the tip of the stomach
Yes, No, I can not answer
c. Heartburn
Yes, No, I can not answer
d. Sour and/or bitter and/or nasty belch
Yes, No, I can not answer
e. Unpleasant sensations below the ribs on the right
Yes, No, I can not answer
f. Unpleasant sensations below the ribs on the left
Yes, No, I can not answer
g. Pains in the upper abdomen or nausea on fasting
Yes, No, I can not answer
h. Feeling bloated after moderate amounts of food
Yes, No, I can not answer
i. Intestinal murmur after food
Yes, No, I can not answer
j. Intestinal murmur after milk
Yes, No, I can not answer
k. Hemorrhoids
Yes, No, I can not answer
l. Liquid or semi-liquid stool very often
Yes, No, I can not answer
m. Intensive urges to defecate
Yes, No, I can not answer
n. Stool leaves traces on the lavatory bowl
Yes, No, I can not answer
o. Undigested food in stool very often
Yes, No, I can not answer
p. Fragmented ("sheep's") stool
Yes, No, I can not answer
q. Constipation
Yes, No, I can not answer
r. Stool with sour smell
Yes, No, I can not answer
s. Stool with rotten smell
Yes, No, I can not answer
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