Familial IPF Questionnaire Form

IMPORTANT: In the late Fall of 2005, this form stopped functioning when, due to security concerns, Netcarrier stopped supporting MAILTO.EXE, the CGI executable required to run it. Efforts are being made to restore its functionality as soon as possible.

Familial IPF Questionnaire Form

Please fill out this form to participate in ongoing studies of Idiopathic Pulmonary Fibrosis (IPF). Results will, with your permission (see below), be sent to the National Institute of Health (NIH) in Bethesda, MD and to Vanderbilt University. Thanks!

Important--All information provided herein is kept strictly confidential. I never reveal your personal information or use it for any purpose other than that for which it has been provided.

Contact Information

If you want to be contacted in the future or just want to provide contact information, please fill out the following section. Except for the first question, this section is optional.

Do you wish to be contacted in the future (required)? Yes No

Name

Address 1

Address 2

City

State

ZIP/Postal Code

Country

Phone number

Email address

If you have a website, what is the address? http://

Survey Questions

The following section is the main part of the survey. Please try to fill in as many fields as possible. Hopefully, the more information we collect, the more meaningful the data will be. Note: the last question is required.

1. How many cases of IPF have there been in your family in total?

2. How many generations of your family have had IPF?

3. On what side (or sides) of your family has IPF occurred? Mother's Father's Both

4. Do you currently have IPF? Yes No

5. What is your age?

6. What is your gender? Female Male

7. In your opinion, what is the most likely cause of IPF in you and/or your family? Include if possible any inherited, environmental, geographic, industrial, or medically associated causes. If you have no idea, please indicate as such.

8. Please describe you and/or your family's particular history with respect to IPF and any pertinent information that you feel is important, including whether or not you feel that there is a familial component to IPF:

9. IMPORTANT--Do you hereby authorize the release of this information ONLY to the medical institutions performing IPF research studies (not insurance companies!) that are detailed above (required)? Yes No

Thank you for taking out the time to complete this form. Hopefully, we can add to the medical community's awareness of the pervasiveness and often widely varying characteristics of this terrible disease, and perhaps in doing so, help to identify it's cause.

My sincere hope is that with additional information comes additional progress.

Roger Stevens
Norristown, PA

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