1) |
What city/state were you in when you first heard of Valley Fever?
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2) |
Did you first hear of Valley Fever
before or
after your symptoms?
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3) |
If after, what city and state were you in when you first discovered your Valley Fever infection?
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4) |
What was your age when you were first diagnosed with Valley Fever?
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5) |
If you knew of Valley Fever before your infection, did you know that Valley Fever could
be contracted in the area you picked it up?
Yes
No
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6) |
Which endemic area listed below is the place where you believe you inhaled the
spores that led to your Valley Fever?
These endemic areas are places where the fungi (Coccidioides sp.) have been known to grow and cause Valley Fever (coccidioidomycosis).
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7) |
Were you:
an endemic area prior to your diagnosis? (Please check any or all that apply)
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8) |
How long after being in the endemic area did you get sick with Valley Fever?
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9) |
What was the city and state where you believe you initially inhaled the Coccidioides sp. that caused your Valley Fever infection?
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10) |
Were you diagnosed with Valley Fever but were never in an endemic area?
Yes
No
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11) |
What was the month and year of the onset of your Valley Fever symptoms?
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12) |
If your Valley Fever symptoms did not occur until after leaving an endemic area, how
much time elapsed between your departure from any endemic areas and your symptoms?
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13) |
Do you believe it was worth being in the endemic area now that you have experienced a Valley Fever infection?
Yes
No
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14) |
If you were diagnosed with Valley Fever, please check all that apply to your case:
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15) |
If you had a disseminated case of Valley Fever, where did your Valley Fever disseminate?
Please check all that apply.
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16) |
Have your Valley Fever symptoms reactivated?
Yes
No
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17) |
If so, how long after your original diagnosis?
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18) |
Has your doctor informed you of possible long-term effects due to your Valley Fever infection?
Yes
No
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19) | What was your titer at the time of your Valley Fever diagnosis?
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20) | If known, what is your current titer?
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21) | Were you put on any drugs to treat your Valley Fever?
Yes
No
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22) | If yes, please list which drugs you used and what dosage
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23) | How long were you taking the drugs for Valley Fever?
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24) | Did/do you have complications because of the drugs? Please list the complications:
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25) | Did you lose your hair due to the drugs given?
Yes
No
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26) | If so, has it grown back yet?
Yes
No
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27) | If known, please state which drug you believe caused your hair loss
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28) | Do you feel the drugs helped to fight your infection?
Yes
No
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29) | If you are or were on medication to treat your Valley Fever illness for a long time,
what was the cost per year? $
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30) | What was the overall out-of-pocket expense for your Valley Fever, including any hospitalization,
doctor visits, or other assistance? $
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31) | How much time did you lose from school or work because of Valley Fever?
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32) | Have you lost your insurance or opportunities to get some insurance plans because of Valley Fever?
Yes No
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33) | Please check all the following symptoms of your Valley Fever infection:
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34) | Do you still have any of the above symptoms? If so, which ones?
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35) | Please list all your heath issues prior to Valley Fever:
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36) | Please list all health issues that occurred since your Valley Fever infection, whether you believe they are related to Valley Fever or not:
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37) | Do you believe Valley Fever contributes to any of the above conditions? Yes No
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38) | Were you pregnant when you had Valley Fever? Yes No
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39) | If yes, was it in your third trimester of pregnancy? Yes No
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40) | Did your child suffer any problems as a result of your Valley Fever infection? Yes No
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41) | If yes, please explain:
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42) | Are you an organ transplant recipient? Yes No
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43) | If yes, was the transplantation before or after your Valley Fever infection? before after
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44) | Do you know anyone who donated an organ after a Valley Fever infection? Yes No
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45) | Do you know anyone who passed away from Valley Fever who donated organs? Yes No
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46) | Do you plan to be an organ donor? Yes No
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47) | Have you donated blood immediately prior to or during your infection? Yes No
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48) | Have you donated blood since your Valley Fever infection? Yes No
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