michigan immune deficiency foundation

The questionnaire below is designed to provide the PI community with statistical data in order to help formulate plans to address Primary Immunodeficiencies.

Our goal is to compile as much information as possible about PI. Doing so will enable us to effectively promote awareness of PI diseases as well as assist researchers in developing improved treatments and possibly even cures.

1. How Would you describe yourself?
A primary care physician
An immunology specialist
A hematology specialist
An infectious disease specialist
A pulmonary specialist
I have already been diagnosed with PI
A friend, family of patient
I think I may have PI
Other

2. Please provide information about the patient that has already been diagnosed with PI:

Patient's Exact Diagnosis
3. Patient's Date of Birth   

4. Patient's Ethnic Background

Caucasion
African American
Hispanic
Asian
Pacific Islander
Native American
Other
 

 

5. Is the patient seeing an immunologist?
 Yes      No 
If not, please indicate other. 

6. Is the patient currently receiving IVIG treatments?
Yes      No 
If so, please provide the brand or manufacturers name.

Where are you recieving your infusion at?
Home      Infusion center 
7. How many times/ how often has the patient been hospitalized for a PI related illness?
What illness(es)?
8. Does the patient have any other major related disorders?
9. Below are the 10 Warning Signs of Primary Immunodeficiency.
    Please check any that apply to you.
Eight or more new ear infections within 1 year

 
Two or more serious sinus infections within 1 year
Two or more months on antibiotics with little effect
Two or more cases of pneumonia within 1 year
Failure of an infant to gain weight or grow normally
Recurrent, deep skin or organ abscesses
Persistent thrush in mouth or elsewhere on skin, after age
Need for intravenous antibiotics to clear infections
Two or more deep-seated infections
A family history of Primary Immunodeficiency
If someone you know is affected by two or more of the following signs, speak to your doctor about the possible presence of Primary Immunodeficiency.

The Michigan Immunodefiency Foundation welcomes your comments or suggestions. If you would like to contact us, please write to us in the message box provided. If your message requires a response, please include your contact information.

Comments or Suggestions:

 

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