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Application
Admission
SiteMap
Application
Admission
SiteMap
Application Form

C.I.D.P.
and Other Autoimmune Diseases (AID)

(AHSCT)

APPLICATION FORM
The following questionnaire is required to define whether HSCT is a meaningful and safe treatment option. This questionnaire must be accompanied by the most recent medical reports documenting the course of disease, previous treatment and past and current functional status.
First Name
Last Name
(kg)
(in cm)
 
PREVIOUS HSCT TREATMENT
Select from the drop down list
Year
MEDICAL INFORMATION
(Autoimmune diseases - AID)
Other Diagnosis
ORGANS FUNCTION
If you have this information, please specify:
(in percent)
(in percent)
Systolic and Diastolic
Alveolar Volume
(PaO2)
(CRP)
or WHO Performance Status
SYMPTOMS OF THE DISEASE
Specify year
How old
 
RELAPSES OF THE DISEASE
Specify how many
Specify how many
Specify year, month, day
Specify year, month, day
PREVIOUS & CURRENT TREATMENT
#1
(Years)
Dose (each infusion)
During treatment
(side effects/ lack of efficacy/neutralizing antibodies)
(yes/no)
#2
(Years)
Dose (each infusion)
During treatment
(side effects/ lack of efficacy/neutralizing antibodies)
(yes/no)
#3
(Years)
Dose (each infusion)
During treatment
(side effects/ lack of efficacy/neutralizing antibodies)
(yes/no)
OTHER
(Years)
Dose (each infusion)
During treatment
(side effects/ lack of efficacy/neutralizing antibodies)
(yes/no)
SYMPTOMATIC TREATMENT
(specify drug and dose)
(specify drug and dose)
(specify drug and dose)
(specify drug and dose)
(specify drug and dose)
 
ELECTROMYONEUROGRAPHY (EMG FOR CIDP)
Specify Year
Signs of worsening
 
LUMBAR PUNCTURE (LP FOR CIDP)
Year of Last Puncture
 
ALLERGIES
CONCURRENT ILLNESSES
#1
#2
#3
 
CURRENT TREATING NEUROLOGIST
 
At Your Discretion