Questionaire

National Eosinophilia-Myalgia Syndrome Network

Questionnaire

There have been no new large-scale studies since the early 1990s on the progressive effects of EMS
and none are in the works that we know of. This disease affects people in many different ways and treatment
of the illness also varies from person to person.

In order to gather the latest facts on this ailment, NEMSN is developing a data base in order to gather the
most up-to-date information for our members.

Please fill out this short questionnaire. All names will be kept confidential.

If you would like a response to your questionnaire, please be sure an fill in your email address.

First Name

Last Name

State/Province

Country

E-mail Address

Please identify and describe yourself:

Age

Sex Male Female

Have you ever taken L-tryptophan supplements or another product with tryptophan in it? Yes No

What year did you develop EMS?

Were blood tests done at the time? Yes No

Did your blood tests show a high eosinophil count? Yes No

Were you diagnosed with EMS or something else?

What were your first symptoms?

Have your symptoms gotten better or worse since you were first affected? Better Worse

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.