Adult CVS Survey
Cyclic Vomiting Syndrome




******PLEASE NOTE: This survey is not sponsored nor sanctioned by the Cyclic Vomiting Syndrome Association. Rather, it is an effort to better understand adult CVS, by the group of adults with CVS (and others with an interest in adult CVS) who have contributed to and created this website.

ALL THE INFORMATION RECEIVED FROM RESPONSES TO THE SURVEY BELOW WILL BE CONFIDENTIAL, AND WILL ONLY BE USED TO COMPILE STATISTICS TO HELP UNDERSTAND CVS IN ADULT PATIENTS.******


Please fill out the following form as completely as possible. DO NOT hit the [ENTER] button because this will send your form before you have completed it. Instead fill out the entire form and then click on the [SEND] button at the bottom. If you DO forget and hit [ENTER], just hit the [BACK] option on your web browser, come back and finish filling out the form and resend it. When we get the complete version, we will disregard the partial one.

***NOTE*** If you do not have enough room for your answer on any section of the survey, please go to the comment section at the bottem and give a more complete answer.




Name:
Birthdate:
Current age:
Age at first episode:
Telephone Number:
Email Address:
Current Street Address:
Current City, State, Zip Code:




Did any specific incidents or events possibly precipitate your first episode? (Please mark with an X)
Accident
Pregnancy
Illness
Surgery
Other
Unsure

 If yes, what were the circumstances?




Please rate on a scale of 1-10, with 1 being the least intense and 10 being the most intense, the following symptoms.
Nausea
Vomiting
Pain
Vertigo
Lethergy
Diarrhea
Other

 If you selected "Other", what other symptom(s) is the
most intense?




How frequent are your episodes?
At what time of day do episodes begin?
How long do they typically last?
How intense do your episodes become?
What is your health status between episodes?
Do you know, or suspect, that certain things trigger episodes?
If you know of, or suspect, triggers, what are they?





What medications are you currently taking? At what dosages? How long have you been on each? Please fill in on the chart below.
Medication Doseage How Long

What medications, past or present, have worked well for you?




Have you ever taken vitamins, minerals or herbal supplements?
(Please mark with an X)
Yes
No
If so, what types and at what dosages?
Which worked well for you?
Have you found any supplements that you believe have relieved any of your
CVS symptoms?






Have you ever used, or are you currently, using any forms of alternative medicine? (Biofeedback, chiropractic care, accupressure, accupuncture, other?)
Yes
No
To what effect?





What type of doctor has provided you with the best treatment for CVS?
(Please mark with an X)
Primary Care Specialist
Gastroenterologist
Neurologist
Endrocrinologist
Other
Do you think this doctor would agree to see other patients for CVS diagnosis
and care?
Yes
No
Possibly
Please list Doctor?s name, address, and telephone # below:
Doctor's Name:
Mailing Address:
Telephone Number:




Please list diagnostic testing that you have had done and the results of those tests:
Blood Work
CT Scan
MRI
Endoscopy
Other Diagnostic Tests





Do you have a family history of migraine in a blood relative?
Yes
No
Unsure
If yes, who?





Additional Comments:





Please feel free to email or telephone if you have questions about the survey:

Julie Kennedy
1533 McAfee Street
St. Paul, MN 55106
651-771-4436
jul1533@aol.com








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