SECTION A -- General Information

Check the box that applies, or type in information requested.

1. Have you been diagnosised with Stills Disease by a doctor?
   Yes No Suspected by doctor Suspected by me
   
2. We would like to send you some literature. What is your mailing address? This Information Is Optional.
   

   Name     
   Street   
   City     
   State    
   Zip Code 
   e-mail   
                                 

3. What is your age? 0-10 years of age, 11-15 years of age, 16-21 years of age, 22-30 years of age, 31-40 years of age, 41 - 50 years of age, 51 - 60 years of age, 61-70 years of age, 71 + years of age.
   
4. Gender: Female, Male
   
5. Race/Ethnicity:
   African American or Black
   American Indian or Alaska Native or Native Hawaiian
   Asian, Asian American or Pacific Islander
   Mexican American/Chicano
   Puerto Rican
   White/Caucasian
   Other (Please specify):
   
6. If you have more than 1 autoimmune disease, please list them:
   
   
7. Do you have other first degree relatives (mother, father, sibling, aunt, uncle, grandparent, grandchild) with autoimmune disease even in remission? Yes, No.
   
8. If you have answered yes to question 6, please list the disease/s and their relationship/s to you.
   
   
9. Current Employment Status:
   Employed
   Retired
   Student
   Disabled
   Not employed but available for work
   Not employed and not available for work
   
10. If you work or worked, what was your occupation?
    
    
11. Has your occupation changed as a result of Stills?
    Yes No
    If Yes what was your former occupation?
    
12. Has your work/school schedule changed as a result of Stills?Yes No
    If Yes, please indicate how your work schedule has changed?
    Work/School less hours
    Work/School less days or take more days off
    Other (Please specify):
    
13. Have you ever been told you have Rosecea?Yes No
    
    

Back to Top

SECTION B -- Pre-Treatment & Diagnosis

Check the box that applies, or type in information requested.

1. What were your initial symptoms?
   Fever
   Rash
   Joint Swelling
   Joint Pain
   Chest Pain or Shortness of breathe when lying back
   Pleurisy
   Sore Throat
   Night or Day Sweats
   Generalized Achiness
   Swollen Lymph Nodes
   Fatigue
   Muscle Weakness
   Abdominal Pain
   Vague feeling of not being well
   Eye pain or irritation
   Lack of appetite
   Hair Loss
   
2. How old were you when Stills first started?
   
3. Did your first Stills flare follow:
   Surgery
   Viral or bacterial illness such as the flu
   No apparent incident or illness - came out of the blue.
   Stress or traumatic incident
   Other (Please specify):
   
4. Answer These Questions if you have Juvenile Rheumatoid Arthritis.
   a.Was it difficult to get a diagnosis? Yes, No.
   b.Were you diagnosised by a: Pediatrician, Family Practice, Rheumatologist
   c. How long did it take to get a correct diagnosis?
   d. If you were incorrectly diagnosed initially, list them:
   e. Before treatment did Still's cause your child to be developmentally delayed?
   Yes No. If yes please specify:
   
   
5. Answer these questions if you have Adult Onset Stills Disease.
   a. Was it difficult to get a diagnosis? Yes, No.
   b. How long did it take to get a correct diagnosis?
   c. If you were incorrectly diagnosed initially, list them:
   d. Was it ever implied by a physician that you were:
   Symptoms In Your Head.
   Chronic Complainer.
   Too Concerned / Obsessed About Your Health.
   Depressed
   
6. After your first flare, have you noticed any of the following precedes additional flares:
   Surgery
   Viral or bacterial illness such as the flu
   No apparent incident or illness - came out of the blue.
   Stress or traumatic incident
   Other (Please specify):
   
7. How many flares have you had in the last year
   and how long did they last
   
8. Before your first flare did you have a hepatitis B vaccination:
   0 - 3 months before
   4 - 6 months before
   7 - 12 months before
   Did not have a hepatitis B vaccination within the year before my first flare.
   
   Back to Top

SECTION C -- Treatment and Life Style Changes

Check the box that applies, or type in information requested.

1. What is your status at this time?
   Active Flare or Acute Stage of Stills Disease (Go to question 2)
   Some control with medication - but still have some symptoms(Go to question 2)
   Control/remission with medication without any symptoms(Go to question 3)
   Remission without any medications(Go to question 4)
   
2. a.What were your symptoms during the last month? After you answer a & b go to question 5.
   Fever:105+104 - 104.9103 - 103.9102 - 102.9101-101.9100.5-100.9 Low Grade Fever: 99-99.9 100 - 100.5
   Rash
   Joint Swelling
   Joint Pain: KneeHip Shoulder Elbow AnkleWrist Neck Back
   Pericarditis /Pericardial Effusion
   Myocarditis
   Pleurisy/Pleural Effusion
   Sore Throat
   Night or Day Sweats
   Generalized Achiness
   Swollen Lymph Nodes
   Fatigue
   Muscle Weakness
   Abdominal Pain
   Chest Pain
   Vague feeling of not being well
   Eye pain or irritation
   Lack of appetite
   Slow thinking, problems concentrating or forming thoughts.
   Short-term memory loss
   Chronically elevated ESR
   Hair Loss
   b. What is your level of activity?
   active - able to work and play without problems
   active but need to take nap once or twice a day
   Inactive need to rest most of the time but can do own care & prepare meals etc.
   Bedridden but able to do own self care.
   Bedridden - need help with own self care.
   
3. a. How Long have you been Controlled with medications After you answer a & b go to question 5.
   b. What is your level of activity?
   active - able to work and play without problems
   active but need to take nap once or twice a day
   Inactive need to rest most of the time but can do own care & prepare meals etc.
   Bedridden but able to do own self care.
   Bedridden - need help with own self care.
   
4. a. How long have you been in remission without any symptoms or medication required?
   b. Which of these medications were you on before going into remission and there dosage?
   Aspirin: Dosage How many doses a day
   Plaquenil: Dosage How many doses a day
   Prednisone: Dosage How many doses a day
   Methotrexate: Dosage How many doses a day
   Enbrel: Dosage How many doses a day
   Other med: Dosage How many doses a day
   Other med: Dosage How many doses a day
   Other med: Dosage How many doses a day
   c. What is your level of activity?
   active - able to work and play without problems
   active but need to take nap once or twice a day
   Inactive need to rest most of the time but can do own care & prepare meals etc.
   Bedridden but able to do own self care.
   Bedridden - need help with own self care.
   
5. Which of these medications are you currently on if any?
   Aspirin: Dosage How many doses a day
   Plaquenil: Dosage How many doses a day
   Prednisone: Dosage How many doses a day
   Methotrexate: Dosage How many doses a day
   Enbrel: Dosage How many doses a day
   Other med: Dosage How many doses a day
   Other med: Dosage How many doses a day
   Other med: Dosage How many doses a day
   
6. If you have had Stills for 2 or more years. Which Season of the year are you more apt to be ill the most:
   Winter
   Spring
   Summer.
   Fall
   Seasons don't seem to make a difference
   If you have had Stills for 2 or more years. Which Season of the year are you more apt to be well the most:
   Winter
   Spring
   Summer.
   Fall
   Seasons don't seem to make a difference
   
7. Do you have a hypersensitivity to the sun? Yes, No.
   
8. Please enter any additional comments regarding how stills has changed your life.
   
   
   

Back to Top

FORM SUBMISSION

Thank you for taking the time to answer the questions in our survey.

The statistic from this survey will be printed periodically in our Newsletter.

Or Print and Mail to:

     

Back to Top