National Eosinophilia-Myalgia Syndrome Network
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 Questionnaire

 

This questionnaire is for those who have been diagnosed with EMS and also for those who suspect they may have EMS though have no diagnosis. There have been no new large-scale studies since the early 1990s on the progressive effects of EMS, and none are in the works now. EMS affects people in many different ways, and although there is no cure for EMS, how the symptoms of the illness are managed varies from person to person.

In order to gather the latest facts on this disease, NEMSN is collecting data. We would also like to keep in touch with you and answer your questions, if we can. Please fill out this questionnaire. All names will be kept confidential.

Please note, all fields marked wtih
* are required.
First Name *
 
Last Name *  
City *  
State/Province *  
Country *  
E-mail Address *  

Please identify and describe yourself:

Age *
Sex *  

Have you ever taken L-tryptophan supplements?  

Have you ever taken other products containing L-Tryptophan?  

Have you ever taken 5-HTP supplements? 


Have you ever taken other products containing 5-HTP? 


Have you taken any other supplement that you suspect of making you sick with EMS-like symptoms? 


What year did you develop EMS or EMS-like symptoms?
 


Describe the timing of taking supplements and of getting sick.

 

Were blood tests done at the time you got sick?     


Did your blood tests show a high eosinophil count (a type of white blood cell)?  

Were you diagnosed with EMS? 

Were you diagnosed something else?   

 

What were your first symptoms?
 

Have your symptoms changed with time? 

Have any of your symptoms gotten better since you were first affected?  Please describe.


Have any of your symptoms gotten worse since you were first affected?  Please describe.

 

What symptoms affect your life most?


What do you do for pain and symptom relief?
 

Do you have any additional comments to add?

 

Thank you for your input.