Albador ATM Symptom Checker Questionnaire

Albador ATM Advanced Technologies Medicine
Symptom Checker Questionnaire

We are interested in some things about you and your health.
Please answer as many the questions yourself by choosing the selection that best applies to you.
There are no “right or “wrong” answers.

PERSONAL DATA MANAGEMENT STATEMENT
The information that you provide will remain strictly confidential.
It will be used exclusively by Albador ATM experts to establish your personal medical condition in terms to propose you the proper treatment solution.

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1/6. YOUR GENERAL PERSONAL DATA

Name *

First

Middle

Last

Gender *MaleFemaleOther

Birthday Day/Month/Year *

Country *

City *

Postal Code *

Postal Address 1 *

Postal Address 2 (optional)

House Number *

Email Address *

Phone Type *MobileLandlineOther

Country Phone Code *

Phone Number *

Insurance Company

Insurance Number

Height / cm

Weight / kg

2/6. YOUR IMMUNE SYSTEM CONDITION

Do you have any of the following immune system disorders?

• Gulliain-Barre syndrome
• Hashimoto’s thyroiditis
• Transverse myelitis
• Immune mediated thrombocytopenia
• Pemphigoid
• Rheumatoid arthritis
• Spondyloarthritis
• Systemic lupus erythematosus
• Vasculitis
• Graves’ disease
• Inflammatory bowel diseases – ulcerative colitis – Crohn’s disease – intermediate colitis …
• Other autoimmune arthritis
• Dermatopolymyositis
• Anti-phospholipid antibody syndrome
• Psoriasis
• Pernicious anaemia
• Multiple sclerosis
• Systemic sclerosis
• Sjogren disease
• Acute disseminated encephalomyelitis
• Pemphigus vulgaris
• Alopecia areata
• OTHER

If you've selected OTHER then please describe here your disorder

3/6. YOUR GENERAL HEALTH CONDITION – TYPE 1

It was hard to do my usual work / studies

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I was afraid of dying

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I avoided leaving the house because of my cough

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I tended to isolate myself

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I was afraid of getting sick

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I felt weak

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

My sexual activity was affected

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

Immunoglobulin therapy bothered me

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

It was difficult to carry out my usual leisure activities

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I felt uncomfortable because of my skin problems (spots, redness, rashes, infections)

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I found it difficult to relate to people I spend time with

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I felt I was a sick person

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I was embarrassed

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I was afraid that I might get infected with other people's illnesses

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I felt troubled by relationships with other patients who have the same disease

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

I felt tired

• NEVER
• RARELY
• SOMETIMES
• OFTEN
• ALWAYS

4/6. YOUR GENERAL HEALTH CONDITION – TYPE 2

Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Do you have any trouble taking a long walk?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Do you have any trouble taking a short walk outside of the house?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Do you need to stay in bed or a chair during the day?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Do you need help with eating, dressing, washing yourself or using the toilet?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

5/6. YOUR GENERAL HEALTH CONDITION DURING THE PAST WEEK

Were you limited in doing either your work or other daily activities?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Were you limited in pursuing your hobbies or other leisure time activities?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Were you short of breath?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you had pain?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Did you need to rest?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you had trouble sleeping?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you felt weak?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you lacked appetite?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you felt nauseated?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you vomited?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you been constipated?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you had diarrhea?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Were you fired?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Did pain interfere with your daily activities?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you had difficulty in concentrating on things, like reading a newspaper or watching television?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Did you feel tense?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Did you worry?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Did you feel irritable?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Did you feel depressed?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Have you had difficulty remembering things?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Has your physical condition or medical treatment interfered with your family life?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Has your physical condition or medical treatment interfered with your social activities?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

Has your physical condition or medical treatment caused you financial difficulties?

• NOT AT ALL
• A LITTLE
• QUITE A BIT
• VERY MUCH

6/6. YOUR PHYSICAL SYMPTOMS DURING PAST 4 WEEKS

Stomach pain

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Back pain

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Pain in your arms, legs, or joints (knees, hips …)

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Menstrual cramps or other problems with your periods [Women only]

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Headaches

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Chest pain

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Dizziness

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Fainting spells

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Feeling your heart pound or race

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Shortness of breath

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Pain or problems during sexual intercourse

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Constipation, loose bowels, or diarrhea

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Nausea, gas, or indigestion

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Feeling tired or having low energy

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

Trouble sleeping

• NOT BOTHERED AT ALL
• BOTHERED A LITTLE
• BOTHERED A LOT

List of medications that you're taking

Other information about your health condition or your current treatment that you would like to share with us

1 Did I

Satisfaction Rating of this questionnaire (0 = low, 10 = high)

Selected Value: 0

Consent to Medical purposes *

• By submitting this Albador ATM Questionnaire, I agree to the use of my personal information for medical purposes.

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