# Dr. Bruno Survey



## mazzy (Feb 20, 1999)

Dear Friends: Dr. Richard Bruno is doing an International Survey to gather information about the ME/poliovirus link as well as raise awareness that ME and FM may actually be symptoms of Post-Polio Sequelae in some people. The National ME/FM Action Network is helping Dr. Bruno by circulating this Survey to as many people as we can. Once you receive this Survey, would you please also pass this Survey on to as many people as you can who have been diagnosed with Myalgic Encephalomyelitis / Chronic Fatigue Syndrome or Fibromyalgia (ME/CFS and FM). Please see our newsletter No. 44, October / November 2000 issue for more details on Dr. Bruno's work. If you are not a member and not receiving our newsletter, please email me and I will be pleased to forward the information to you. Lydia E. Neilson, President CEO NATIONAL ME/FM ACTION NETWORK 3836 Carling Avenue Nepean, ON K2K 2Y6 Canada Tel/Fax: (613) 829-6667 E-mail: ag922###ncf.ca Web: http://www3.sympatico.ca/me-fm.action/ -----------------------------------------------------------------------------PLEASE return this survey to Dr. Richard L. Bruno 151 Prospect AvenueBox 17AHackensack, NJ 07601 USA or e-mail harvestctr###AOL.COM 2001 International CFS/ME/FM Survey Today's Date ____ /____ /____ Date of Birth ____ /____ /____ Gender_____ Age ______Marital Status _____________ Years of Schooling ______ Number of Brothers/Sisters ______ Occupation _____________________ If you are NOT working now, why not?____________________ Where do you live?______________________________________________________________________ NO | YES I was diagnosed by a doctor as having paralytic polio. In what year? ______ NO | YES I was diagnosed by a doctor as having non-paralytic polio. In what year? ______ NO | YES Someone (maybe a family member) told me I had polio as a child. In what year? ______ NO | YES As a child I had an illness with a fever that made me very fatigued for several days. In what year? ______ If YES to any of the above: I had a fever for ______ days I had a stiff neck for ______ days I was hospitalized for ______ days I was living in this city & state/province & country________________________________ when I got sick. At that time these muscles were weakened: O Neck O Back O Left LEG O Right O Left ARM O Right At that time these muscles were paralyzed: O Neck O Back O Left LEG O Right O Left ARM O Right NO | YES Someone in my house had polio when I had these symptoms. If YES who had polio? ________________________________ Who else in your family had similar symptoms at the same time? ____________________ What symptoms did they have? ___________________________________________ Please CIRCLE BOTH the FREQUENCY AND SEVERITY that best describe how you feel on a daily basis: neversometimes mildfrequently have moderate FATIGUEalways severe neversometimes mildfrequently have moderate MUSCLE WEAKNESSalways severe neversometimes mildfrequently have moderate [ ARM | LEG ] MUSCLE PAINalways severe neversometimes mildfrequently have moderate JOINT PAINalways severe neversometimes mildfrequently have moderate BACK | NECK PAINalways severe neversometimes mildfrequently have moderate DIFFICULTY SLEEPINGalways severe neversometimes mildfrequently have moderate DIFFICULTY STAYING AWAKE DURING THE DAYalways severe neversometimes mildfrequently have moderate DIFFICULTY CONCENTRATINGalways severe neversometimes mildfrequently have moderate DIFFICULTY FOCUSING MY ATTENTIONalways severe neversometimes mildfrequently have moderate DIFFICULTY KEEPING MY MIND FROM WANDERINGalways severe neversometimes mildfrequently have moderate DIFFICULTY REMEMBERING INFORMATIONalways severe neversometimes mildfrequently have moderate DIFFICULTY THINKING OF WORDS I WANT TO SAYalways severe neversometimes mildfrequently have moderate DIFFICULTY THINKING CLEARLYalways severe Symptoms get worse with: COLD EXPOSURE: NO | YES EMOTIONAL STRESS: NO | YES PHYSICAL OVEREXERTION: NO | YES NO | YES The symptoms I have today came on slowly over time. ( Over how many months, years: _________ ) NO | YES The symptoms I have today began immediately after having a flu-like illness. NO | YES The symptoms I have today began after an [ ACCIDENT | SURGERY ] NO | YES I [ snore | wake short of breath | wake with my heart pounding at night | wake NOT feeling rested ] NO | YES My muscles twitch or jump [ as I FALL asleep | DURING the night] NO | YES I have been diagnosed with a "slow" thyroid (hypothyroidism). NO | YES I have been diagnosed with depression and I am depressed now. I have FAINTED about _______ times in my life before new symptoms. Ihave FAINTED about _______ times since new symptoms. I have had great difficulty waking up after a general anesthetic since I have had new symptoms: NO | YES | HAVEN'T HAD ANESTHETIC. Please CIRCLE the answer that best describes how you usually think, feel or act BEFORE you had new symptoms. If you are not working now, CIRCLE the answer that best describes how you acted when you were working. Do YOU... True False ... enjoy competition? True False ... consider yourself to be "hard driving?" True False ... set at least one deadline per day for yourself? True False ... have a temper that's hard to control, "fiery?" True False ... set at least one deadline per week for yourself? True False ... usually wake up in the morning NOT feeling well rested? True False ... usually spend LESS than five days on an average vacation? True False ... spend MORE than eight hours per week working overtime? True False Have you taken less than one vacation per year during the past five years? True False Is it very important for you personally to get ahead in life? TOTALLY OPTIONAL (but helpful): Name _____________________________ E-mail____________ Phone ___________ PLEASE return to Dr. Richard L. Bruno 151 Prospect Avenue Box 17AHackensack, NJ 07601 USA or e-mail harvestctr###AOL.COM


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