This questionnaire is ONLY for those who know they were infected with Valley Fever (coccidioidomycosis). Please fill out the information below completely and to the best of your knowledge. We thank you in advance for taking the time to fill out this important questionnaire. Our hope is that we can educate the public and bring this issue to national attention, leading to the funding needed to eliminate it forever.

If you feel this questionnaire does not apply to you, then click here to return to the Home Page.
Otherwise, please fill out the questionnaire below. Your input really does matter.

Name:     Male   Female

Email:     Age:

Phone:  

Current city and state:
  

1)	What city/state were you in when you first heard of Valley Fever?
2)	Did you first hear of Valley Fever    before    or    after your symptoms?
3)	If after, what city and state were you in when you first discovered your Valley Fever infection?
4)	What was your age when you were first diagnosed with Valley Fever?
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
6)	Which endemic area listed below is the place where you believe you inhaled the spores that led to your Valley Fever? Arizona New Mexico Mexico California Nevada Central America Texas Utah South America These endemic areas are places where the fungi (Coccidioides sp.) have been known to grow and cause Valley Fever (coccidioidomycosis).
7)	Were you: a resident living in working in relocating to retiring to in the military or passing through an endemic area prior to your diagnosis? (Please check any or all that apply)
8)	How long after being in the endemic area did you get sick with Valley Fever?
9)	What was the city and state where you believe you initially inhaled the Coccidioides sp. that caused your Valley Fever infection?
10)	Were you diagnosed with Valley Fever but were never in an endemic area? Yes    No
11)	What was the month and year of the onset of your Valley Fever symptoms?
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?
13)	Do you believe it was worth being in the endemic area now that you have experienced a Valley Fever infection?  Yes    No
14)	If you were diagnosed with Valley Fever, please check all that apply to your case: Symptoms were barely noticeable Still on medication Sick for a few days Had a disseminated infection Very sick but okay in a few weeks Have continuing complications Sick for months or longer Lost time at school or work
15)	If you had a disseminated case of Valley Fever, where did your Valley Fever disseminate? Please check all that apply. skin bones thyroid lymph nodes joints kidney lungs brain liver heart spine eyes Other:
16)	Have your Valley Fever symptoms reactivated? Yes    No
17)	If so, how long after your original diagnosis?
18)	Has your doctor informed you of possible long-term effects due to your Valley Fever infection? Yes    No
19)	What was your titer at the time of your Valley Fever diagnosis?
20)	If known, what is your current titer?
21)	Were you put on any drugs to treat your Valley Fever? Yes    No
22)	If yes, please list which drugs you used and what dosage
23)	How long were you taking the drugs for Valley Fever?
24)	Did/do you have complications because of the drugs? Please list the complications:
25)	Did you lose your hair due to the drugs given? Yes    No
26)	If so, has it grown back yet? Yes    No
27)	If known, please state which drug you believe caused your hair loss
28)	Do you feel the drugs helped to fight your infection? Yes    No
29)	If you are or were on medication to treat your Valley Fever illness for a long time, what was the cost per year? $
30)	What was the overall out-of-pocket expense for your Valley Fever, including any hospitalization, doctor visits, or other assistance? $
31)	How much time did you lose from school or work because of Valley Fever?
32)	Have you lost your insurance or opportunities to get some insurance plans because of Valley Fever? Yes    No
33)	Please check all the following symptoms of your Valley Fever infection: rash vision problems chest pain wheezing photosensitivity joint pain fever malaise joint swelling chills nausea joint stiffness dizziness loss of appetite leg swelling night sweats weight loss foot swelling chronic coughing muscle aches ankle swelling headaches muscle stiffness burning sensation severe head pain       in foot/feet other:
34)	Do you still have any of the above symptoms? If so, which ones?
35)	Please list all your heath issues prior to Valley Fever:
36)	Please list all health issues that occurred since your Valley Fever infection, whether you believe they are related to Valley Fever or not:
37)	Do you believe Valley Fever contributes to any of the above conditions? Yes    No
38)	Were you pregnant when you had Valley Fever? Yes    No
39)	If yes, was it in your third trimester of pregnancy? Yes    No
40)	Did your child suffer any problems as a result of your Valley Fever infection? Yes    No
41)	If yes, please explain:
42)	Are you an organ transplant recipient? Yes    No
43)	If yes, was the transplantation before or after your Valley Fever infection? before   after
44)	Do you know anyone who donated an organ after a Valley Fever infection? Yes    No
45)	Do you know anyone who passed away from Valley Fever who donated organs? Yes    No
46)	Do you plan to be an organ donor? Yes    No
47)	Have you donated blood immediately prior to or during your infection? Yes    No
48)	Have you donated blood since your Valley Fever infection? Yes    No

Please describe how your Valley Fever case has impacted you and your family's lives. What were some costs of Valley Fever that you experienced? (Lost job, had to drop out of school, off sports team, had to change plans, divorce, abandoned hobbies, incapacitated, etc.) Please add any additional comments and information you would like to share.

Thank you for taking the time to complete our questionnaire.