Symptoms Form

first name last name age your address City Province Postal code Telephone Fax no E-mail address age at diagnosis Describe your symptoms that led to the diagnosis of scleroderma: Describe your current symptoms: What medication do you currently take? ( including over-the-counter)? What medication have you taken in the past and no longer take? ( including over-the-counter)? List the doctors (+ their speciality) that you see on a regular basis: What alternative therapies have you investigated? What surgeries or hospitalizations have you had? Please indicate which of the following you have had: (click the boxes of all that apply) CONDITIONS: Chicken Pox Measles Diabetes Epilepsy Mumps Tonsillitis Asthma Allergies Fractures Sprains Dizziness Skin rashes Rheumatic Fever Cancer Headaches Stroke Ulcers Seizures DENTAL WORK: Amalgam fillings (silver) Porcelain fillings (white) Extractions Appliances Bridges Studs Other conditions: Occupation/Working environment: Water Source: Any other information you would like to share: [Top of this page] [Home] [Stories] [Links] [Support Groups] [About Us] [Memberships] [Contact Us] [News] [the Board] � Scleroderma Society of Canada, Symptoms Form, 2001-2004. Last Update: rdg - Feb 08/04 - Email: [email protected]