Survey of Non-Traditional Treatment in ITP

(This is for information only.  Do not complete survey. The survey input was closed 12/31/01 for tablulation)

I. Identification of Person with ITP

 
First Name  M. I.
Last Name
Address 1 
Address 2 
City           State
Zip/Postal Code
Country    
Telephone
E-mail Address 

Name of person completing form, if other than the person with ITP.

E-mail address of person completing form, if other that the person with ITP.

II. Demographics. 

1.  Gender

Male  Female

2. Date of Birth (month and year mmyyyy)?    MM     YYYY

III. Medical Condition

3. Date diagnosed with ITP (month and year mmyyyy)?  MM   YYYY 

4. What was your platelet count when diagnosed? (check one)

0 - 10,000 31,000 - 40,000 71,000 - 90,000
11,000 - 20,000 41,000 - 50,000 91,000 - 120,000
21,000 - 30,000 51,000 - 70,000 121,000 - 150,000
don't know

5. What were your symptoms at their worst? (check all that apply)

Bruising Fatigue Increased menstrual flow
Bleeding in mouth Bleeding in other parts of the body besides mouth Petechiae (pin point red or purplish marks on the surface of skin) 

6. What is your current platelet count?

0 - 10,000 31,000 - 40,000 71,000 - 90,000
11,000 - 20,000 41,000 - 50,000 91,000 - 120,000
21,000 - 30,000 51,000 - 70,000 121,000 - 150,000
greater than 150,000 don't know

7. How long ago was your most recent platelet count obtained?

Less than 1 month ago 1 - 3  months ago 4 - 6  months ago
More than 6 months ago Don't know

8. What are your current symptoms? (check all that apply)

Bruising Fatigue Increased menstrual flow
Bleeding in mouth Bleeding in other parts of the body besides mouth Petechiae (pin point red or purplish marks on the surface of skin) 
None - Normal bleeding

9. What other medical conditions do you have? (check all that apply)

SLE (Lupus) Leukopenia
Chronic Lymphocytic Leukemia Anemia
Immunodeficiency None of the above

IV. Traditional Treatments

10. - 23.  Select the most appropriate response from the drop down menus below for those treatments that you have tried or are currently using. If you do not make any selection, the default is the displayed response (Never used, No effect, None).  Therefore, NO ACTION is required for those treatments you have NOT tried and NEVER used.  

If there is a traditional treatment that you've taken for your ITP that is not listed, place the name in the "Other" section at the end of the list (Questions 22 and 23).   If you are not sure if the therapy is under the "traditional category", just enter it.  The medical staff will determine if it is in the correct category.

    Describe your use of each treatment or practice
Never used - Never a part of your treatment
Tried to use - Used in the past but have discontinued use
Currently using -Currently a part of your treatment		 Effect on your bleeding (select one if applicable)
No effect - didn't reduce bleeding
Some - had some positive effect 
Normal -bleeding returned to normal 		Effect on your platelet counts (select one if applicable)
No effect - didn't raise counts
Moderate effect - had a moderate or short lived positive effect
Sustained effect - had a long term positive effect on counts		 Side Effects (check one if applicable)
None - No difficult side effects
Mild - Minor and temporary side effects
Moderate - Difficult side effects
Severe - Extreme side effects
  Treatment Use Effect on Bleeding Effect on Platelets Side Effects
10 Anti-D Antibody (Win-Rho SDF)
11 Azathioprine (Imuran)
12 Colchicine
13 Corticosteroids (prednisone dexamethasone, etc.)
14 Cyclophosphamide (Cytoxan)
15 Cyclosporine(Sandimmune)     
16 Danocrine (Danazol)
Treatment Use Effect on Bleeding Effect on Platelets Side Effects
17 Gammaglobulin (IVIG)
18 Protein A Column (Prosorba Column)
19 Rituxan  (Rituximab,  Anti - CD20)
20 Splenectomy
21 Vinca alkaloids (Oncovin, Velban, Vincristine)
22 Other therapy -  Enter name here:
23 Other therapy  - Enter name here:
Treatment Use Effect on Bleeding Effect on Platelets Side Effects

This is the end of the first page.