QUESTIONNAIRE

The following questionnaire describes you previous treatment and current functional status, to define whether HSCT is a meaningful and safe treatment option for you.
This online form must be accompanied by the report of last MRI
(Only the MRI report, no images required.)

Email

Name

First Name

Surname

Last Name

Date of Birth

Country

Weight

(kg)

Hight

(in cm)

PREVIOUS HSCT TREATMENT

Have you ever had HSCT?

Select from the drop down list

The year of previous HSCT

Year

MEDICAL INFORMATION

Diagnosis

(Autoimmune diseases - AID)

Specify other name of Autoimmune Disease

Other Diagnosis

ORGANS FUNCTION

If you have this information, please specify:

Cardiac LV Ejection Fraction

(in percent)

Total Lung Capacity

(in percent)

Pulmonary Artery Pressure

Systolic and Diastolic

DLCO/VA

Alveolar Volume

Partial Pressure of Oxygen

(PaO2)

Serum Bilirubin

Serum Creatinine

C-reactive Protein

(CRP)

Karnofsky Score

or WHO Performance Status

SYMPTOMS OF THE DISEASE

Year of 1st Diagnosis

Specify year

Age of 1st Diagnosis

How old

RELAPSES OF THE DISEASE

Number of relapses since 1st diagnosis

Specify how many

Number of relapses since 1st diagnosis

Specify how many

The Date of the Last Relapse

Specify year, month, day

Time of Progression

Specify year, month, day

PREVIOUS & CURRENT TREATMENT

#1

Drug Name

Duration

(Years)

Number of infusions

Dose (each infusion)

Number of relapses

During treatment

Discontinuation

(side effects/ lack of efficacy/neutralizing antibodies)

Improvement

(yes/no)

#2

Drug Name

Duration

(Years)

Number of infusions

Dose (each infusion)

Number of relapses

During treatment

Discontinuation

(side effects/ lack of efficacy/neutralizing antibodies)

Improvement

(yes/no)

#3

Drug Name

Duration

(Years)

Number of infusions

Dose (each infusion)

Number of relapses

During treatment

Discontinuation

(side effects/ lack of efficacy/neutralizing antibodies)

Improvement

(yes/no)

OTHER

Drug Name

Duration

(Years)

Number of infusions

Dose (each infusion)

Number of relapses

During treatment

Discontinuation

(side effects/ lack of efficacy/neutralizing antibodies)

Improvement

(yes/no)

SYMPTOMATIC TREATMENT

Spasticity

(specify drug and dose)

Fatigue

(specify drug and dose)

Pain

(specify drug and dose)

Urinary symptoms

(specify drug and dose)

Other

(specify drug and dose)

ELECTROMYONEUROGRAPHY (EMG FOR CIDP)

Year of last EMG

Specify Year

Signs of worsening

YES

NO

LUMBAR PUNCTURE (LP FOR CIDP)

Year of Last Puncture (LP for CIDP)

Year of Last Puncture

Protein level

ALLERGIES

Allergies to Food

Allergies to Medications

CONCURRENT ILLNESSES

#1

Specify Type / Year of Diagnosis / Current Treatment

#2

Specify Type / Year of Diagnosis / Current Treatment

#3

Specify Type / Year of Diagnosis / Current Treatment

CURRENT TREATING NEUROLOGIST

Name

Phone

Email

Additional Information

At Your Discretion

Printable version for manual completion

AHSCT RUSSIA

CIDP & Other AID