Future Research

     We need help catching a killer.

     No, we are not the police. We are the online ARDS
     Support Group. Just as detectives require evidence to
     catch killers, the medical community requires
     statistical research to help corner killer diseases to
     help eradicate them. A solid, concise database of both
     victims and survivors, as well as circumstances
     involved in their contracting ARDS will be invaluable
     to medical researchers in their quest to end the
     suffering caused by this deadly syndrome.

     Won't you please help?
 

 

 

Please answer all the questions. Use your mouse to move from one question to the next as hitting the enter key will automatically submit the form. When complete, click the Submit Form button at bottom of the page.

 

      Tell us how to get in touch with you:

First Name
Last Name
Street
City
State
Zip
E-mail
Confirm E-mail
Telephone
Age
Sex Male Female

         Please select one of the following.

A) ARDS Survivor
B) Family/Friend of ARDS Survivor
C) Lost a loved one to ARDS


The following questions relate to the ARDS patient:
Sex of ARDS Patient?   Male Female

Age at time of ARDS crisis?


Condition Pre-ARDS?


How long before ARDS developed?


Duration of ARDS crisis?


Initial condition Post-ARDS?


Current condition Post-ARDS


Post ARDS problems if any?

Additional Comments?

This release hereby authorizes ARDS Support Center, Inc., or their agents, to examine, make copies of, and/or share any and all medical information with the ARDS Support Center Board of Medical Advisors that I have supplied on this questionnaire. 

Agree 

Disagree


Type Full Name Here


 

Thank you for taking the time to complete the survey !


 

Copyright 2000 ASC. All rights reserved.
Revised: October 25, 2003

 

 

 

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