PPS NEW HEALTH PROBLEMS SURVEY

Post-Polio Syndrome
New Health Problems
== Survey ==

Follows is a Free, 39 question survey. If you are unable to use forms, email us for a text version to be mailed back or grab your own via the link:
Survey In Text Format

Click on Graphic to View PPS Survey Results

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.
( 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:
0 to 6 Months 6+ to 12 Months 1+ to 3 Years 3+ to 6 Years
6+ to 10 Years 10+ to 15 Years 15+ to 20 Years
20+ to 25 Years 25+ to 30 Years 30+ to 35 Years 35+ to 40 Years 45+ Years Or Older

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

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.

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 click on the SUBMIT button. You only have one submission, so make sure it's the way you want it before you SUBMIT it.