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Chronic Urticaria Survey

~ICUS - the International Chronic Urticaria Society~ is surveying those that have a condition known as Chronic (lasting longer than 6 weeks) Urticaria (Hives). CU is a symptom and not a disease. It is like a caugh is to a cold. The symptom here are the hives. This survey was created by ordinary people (self-empowered) afflicted by Chronic Urticaria in the hopes that it may one day be used as a guide for further research into this baffling ailment! Please fill out the following information as completely and truthfully as possible. We are itching for all persons that with this condition, take this survey. We plan to take the data gathered and provide it to medical researches.

GENDER
   

AGE
   

WHAT IS YOUR ETHNIC ORIGIN? PLEASE INDICATE ALL THAT APPLY.
    African     African-American     American Indian     Australian
    British     Canadian     Chinese     Croatian
    Danish     Dutch     East Indian     English
    Filipino     Finnish     French     German
    Greek     Hispanic     Hungarian     Irish
    Italian     Japanese     Jewish     Korean
    Lebanese     Norwegian     Polish     Portugese
    Scotish

WHAT COUNTRY DO YOU LIVE IN?

IF YOU LIVE IN THE US, WHAT STATE?

WHAT CITY DO YOU LIVE IN?

PLEASE CLASSIFY YOUR COMMUNITY TYPE?
   

HAVE YOU EVER LIVED IN AN AREA WHERE YOU BELIEVE THE AIR TO BE UNSAFE OR UNHEALTHY?
    Yes     No

DO YOU CURRENTLY LIVE IN SUCH A PLACE?
    Yes     No

HAVE YOU HAD ANY UNUSUAL CHEMICAL EXPOSURE IN THE PAST?
    Yes     No

DO YOU WORK WITH CHEMICAL? (INCLUDING INDUSTRIAL-STRENGTH CLEANING SUPPLIES)
    Yes     No

DO YOU USE HAIR COLORING / DYES?
    Yes     No

DO YOU LIVE IN A NEW HOME? (BUILT IN THE LAST 5 YEARS)
    Yes
    No

WAS YOUR HOME OR WORK RECENTLY RENOVATED?
    Yes
    No

DO YOU HAVE NEW CARPET?
    Yes
    No

DO YOU HAVE GAS HEAT/FIREPLACE?
    Yes
    No

DO YOU HAVE LEAD-BASED PAINT?
    Yes
    No

HAVE YOU MOVED TO A NEW CLIMATE?
    Yes
    No

HAVE YOU MOVED TO AN AREA WITH DIFFERENT POLLENS/ALLERGENS IN THE AIR?
    Yes
    No

DID YOUR FIRST OUTBREAK OCCUR...?
   

DOES TRAVEL EFFECT YOUR OUTBREAKS?
    Yes
    No

ARE YOUR OUTBREAKS SEASONAL?
    Yes
    No

IS THERE A PATTERN TO YOU OUTBREAKS?
    Yes
    No

IF YES, PLEASE EXPLAIN.

IS THERE A PARTICULAR TIME WHEN YOUR OUTBREAKS ARE WORSE?
    Yes
    No

IF YES, WHEN?

DESCRIBE YOUR HEALTH STATUS BEFORE THE URTICARIA STARTED.
   

DO YOU FEEL THAT YOU ARE SICK (ie. cold/flu) LESS OFTEN SINCE YOUR URTICARIA BEGAN?
    Yes
    No

HOW LONG HAVE YOU SUFFERED WITH CHRONIC URTICARIA?
   

AT WHAT AGE DID YOU HAVE YOUR FIRST OUTBREAK OF CHRONIC URTICARIA?
   

HAVE YOU EVER BEEN IN REMISSION?
    Yes
    No

IF YES, DID YOU EVER HAVE AN OUTBREAK FOLLOWING YOUR REMISSION
    Yes
    No

WERE/ARE YOU COMPLETELY HIVE-FREE DURING REMISSION?
    Yes
    No

ARE YOU IN REMISSION NOW?
    Yes
    No

PLEASE INDICATE WHICH HEALTH CARE PROVIDERS YOU HAVE SEEN FOR CHRONIC URTICARIA.
    Acupressurist     Acupuncturist     Allergist     Dermatologist
    Endocrinologist     Gastroenterologist     General practicioner     Hematologist
    Homeopath     Immunologist     Internal medicine practitioner     Nephrologist
    Naturopath     Oncologist     Rheumatologist     Urologist
   Other

WHICH HEALTH PRACTITIONERS DO YOU BELIEVE HAVE HELPED WITH YOUR URTICARIA? CHOOSE ALL THAT APPLY.
    Acupressurist     Acupuncturist     Allergist     Dermatologist
    Endocrinologist     Gastroenterologist     General practicioner     Hematologist
    Homeopath     Immunologist     Internal medicine practitioner     Nephrologist
    Naturopath     Oncologist     Rheumatologist     Urologist
   Other

1)    Weight Loss or Gain?
Have you experienced weight gain or loss? example: --Indicate no change as 0 --Indicate weight loss as a negative ### (-25) --Indicate weight gain as a positive ### (+15) 		+20

2)    Fatigue
Do you experience mental fatigue or drowsiness? 		-5 -4 -3 -2 -1 0 1 2 3 4 5

3)    Weakness
Do you experience muscular or bodily weakness? 		-5 -4 -3 -2 -1 0 1 2 3 4 5

4)    Weakness
Have you felt week? 0 having no weakness to 3 being very weak. 		0 - not week 1 - somewhat weak 2 - usually weak 3 - always weak

5)    Fever
Do you experience fevers with your hives?
    Yes     No

6)    Headaches
    Yes     No

7)    Dizziness
    Yes     No

8)    Fainting
    Yes     No

9)    Muscle spasm
    Yes     No

10)    Loss of conciousness
    Yes     No

11)    Sensitivity or pain of hands and / or feet
    Yes     No

12)    Memory loss
    Yes     No

13)    Ringing in ears
    Yes     No

14)    Loss of hearing
0 - no loss 1 - mild loss 2 - moderate loss 3 - significant loss
    0 - no loss 1 - mild loss 2 - moderate loss 3 - significant loss

15)    Nosebleeds
    Yes     No

16)    Loss of smell
    Yes     No

17)    Sore tongue
    Yes     No

18)    Bleeding gums
    Yes     No

19)    Sores in mouth
    Yes     No

20)    Loss of taste
    Yes     No

21)    Frequent sore throats
    Yes     No

22)    Hoarseness
    Yes     No

23)    Difficulty swallowing
    Yes     No

24)    Anemia
    Yes     No

25)    Bleeding tendency
    Yes     No

26)    Swollen glands
    Yes     No

27)    Tender glands
    Yes     No

28)    Pain in chest
    Yes     No

29)    Irregular heartbeat
    Yes     No

30)    Sudden changes in heart beat
    Yes     No

31)    Shortness of breath
    Yes     No

32)    Difficulty in breathing at night
    Yes     No

33)    Swollen legs or feet
    Yes     No

34)    High blood pressure
    Yes     No

35)    Heart murmurs
    Yes     No

36)    Cough
    Yes     No

37)    Wheezing
    Yes     No

38)    Night sweats
    Yes     No

39)    Nausea
    Yes     No

40)    Vomiting of blood or coffee ground material.
    Yes     No

41)    Stomach pain relieved by food or milk.
    Yes
    No

42)    Yellow jaundice
    Yes
    No

43)    Increasing constipation
    Yes
    No

44)    Persistant diarrhea
    Yes
    No

45)    Blood in stools
    Yes
    No

46)    Black stools
    Yes
    No

47)    Heartburn
    Yes
    No

48)    Difficult urination
    Yes
    No

49)    Pain or burning on urination
    Yes
    No

50)    Blood in urine
    Yes
    No

51)    Cloudy, "smoky urine"
    Yes
    No

52)    Discharge from penis/vagina
    Yes
    No

53)    Frequent urination
    Yes
    No

54)    Getting up at night to pass urine
    Yes
    No

55)    Vaginal dryness
    Yes
    No

56)    Rash/ulcers
    Yes
    No

57)    Sexual difficulties
    Yes
    No

58)    Prostate trouble
    Yes
    No

59)    Easy bruising
    Yes
    No

60)    Skin Redness
    Yes
    No

61)    Rash
    Yes
    No

62)    Hives
    Yes
    No

63)    Sun sensitive
    Yes
    No

64)    Skin tightness
    Yes
    No

65)    Nodules/bumps
    Yes
    No

66)    Hair loss
    Yes
    No

67)    Color changes of hands or feet in the cold
    Yes
    No

68)    Morning stiffness
    Yes
    No

69)    Joint pain
    Yes
    No

70)    Muscle weakness
    Yes
    No

71)    Muscle tenderness
    Yes
    No

72)    Do you drink coffee?
    Yes
    No

73)    Do you smoke?
    Yes
    No

74)    Past smoker
    Yes
    No

75)    Has anyone ever told you to cut down on your drinking?
    Yes
    No

76)    Do you use drugs for reasons that are not medical? If so, list.
    Yes
    No

77)    How many pillows do you sleep on each night?
    Yes
    No

78)    Do you get enough sleep at night?
    Yes
    No

79)    Do you wake up feeling rested?
    Yes
    No

80)    Where do you live?

81)    Do you work outside the home?
    Yes
    No

82)    If yes, what business or industry?

83)    Are your symptoms better or worse at work?
    Yes
    No

84)    MArital status

85)    Hetrosexual
    Yes
    No

86)    # Partners/Fequency

87)    Homosexual
    Yes
    No

88)    # Partners/Fequency

89)    Bi-Sexual
    Yes
    No

90)    # Partners/Fequency

91)    Do you exercise
    Yes
    No

92)    Military service
    Yes
    No

93)    Have you been given a diagnosis?
    Yes
    No

94)    What is it?

95)    How long have you had CU

96)    Have you ever been in remission?
    Yes
    No

97)    Is there a particular time when your symptoms are worse?

98)    What do you think causes your CU?

99)    Have you had a flu shot?
    Yes
    No

100)    Do you travel?
    Yes
    No

101)    Are your symptoms better or worse during travel?

102)    Current medications, dosages include vitamins

103)    Tried medications and dosages, include vitamins

104)    List foods that trigger hives

105)    List activities that trigger hives

106)    Other triggers of hives

107)    Age periods began:

108)    Periods regular:
    Yes
    No

109)    How many days apart:

110)    Fertility treatments?
    Yes
    No

111)    Any pregnancies?
    Yes
    No

112)    Hysterectomy?
    Yes
    No

113)    Estrogen use?
    Yes
    No

114)    Abortions?
    Yes
    No

115)    Menopause
    Yes
    No

116)    Prostrate problems?
    Yes
    No

117)    Impotency?
    Yes
    No