Post-Polio Syndrome
New Health Problems Survey

Download, cut and paste or Email this page to yourself
then complete the survey and email it back to:
scout@skally.net.

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PERSONAL INFO:
This is about the person you are filling in the survey for
who has PPS, either you or someone else you are responding
for. If you're not sure about a response, make a best 
guess answer.
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( PPS = POST POLIO SYNDROME )

* Gender: Female - Male

* Age:
  20 to 30 Years - 31 to 40 Years - 41 to 50 Years -
  51 to 60 Years - 61 to 70 Years - 71 to 80 Years
* Contracted Polio More Than Once at Two Different Times:
  Yes - No
  A small percentage of Polio Survivors contracted Polio
  more than once at different times. Those who have experienced
  multiple infections at different times select the one considered
  to be must significant or most destructive and answer the following
  based on that experience.

* Age When Contracted Polio:

* Which type of Polio:
  Bulbar - Spinal - Both - Neither Diagnosed that I know Of
* Was there Ever An Official Diagnosis of Polio:
  Yes - No
* On A Scale Of 0-10, Rate The Severity of Intial Polio Disability:
  (No Disability, 1=Very Mild and 10=Very Severe:
  No disability - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Have To Use An Iron Lung?:
  Yes - No
* Total Time In Physical Therapy For Initital Polio:
  None 11 months or less - 1 to 2 years - 3 to 4 years
  4 to 5 years - 5 years or more
* Number Of Years Between First Contracting Polio To Experiencing
  First symptoms Of PPS:
  1 to 5 years - 5+ to 10 years - 10+ to 15 years
  15+ to 20 - 20+ years or more
* Time In Hospital And/Or Convalescence In Acute Phase Of The
  Original Polio Virus Infection:
  None - 1 day to 6 months - 6+ to 12 months - 12+ to 18 months
  18+ to 24 months - 24+ months or more

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NEW (SINCE ONSET OF PPS) HEALTH PROBLEMS:
No=No New Health Problem since onset of PPS.
if YES, then just rate the severity of the new health problem from
1 to 10 with 1 being very mild and 10 being very severe.
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* Breathing Difficulties:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Atrophy Of "Affected" Muscles:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Atrophy Of "Unaffected" Muscles:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Problems Concentrating:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* New Weakness In "Affected" Muscles:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* New Weakness In "Unaffected" Muscles:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* New Swallowing Problems:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Fatigue In "Affected" Muscles:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Fatigue In "Unaffected" Muscles:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Overall Fatigue:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Brain Fatigue:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Depression:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Muscles Twitching/Cramping/Jumping:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Sleep Apnea:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Hypopnea, Underventilating Or Periods Of Shallow
  Breathing During  Sleep:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Other Sleeping Problems:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Headaches:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Vision Problems Not Associated With Normal Aging:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Incontinence:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Impotency Or Libido Diminished:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Cardiac Problems:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Cold Intolerance:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Heat Intolerance:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Pain In "Affected" Areas:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Pain In "Unaffected" Areas:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Thyroid Problems:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Allergies:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
* Adverse Reactions To Drugs:
  No -- 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10

Check your responses carefully please then email this to:
scout@skally.net

 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10

Check your responses carefully please then email this to:
scout@skally.net

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