Mycoplasma Registry

Please take the time to fill out the Mycoplasma Registry. Your Identity will be kept confidential.

1. Date
2. Referred By

3. Name	4. Age
5. Phone	6. Fax
7. E-mail	8. Web Site
9. Address	10. City
11. State/Province	12 .Country 13. Zip

14. Date of Positive Micoplasma Blood Test

15. Species Tested For
General Mycoplasma Family	M. Hominis
M. Fermentans (Incognitas)	M. Genitalium
M. Penetrans	M. Pirum
M. Pneumoniae	Other

16. Lab Tested
Institute for Molecular Medicine, University of Ca. Irvine
Immunosciences
Other

17. Original Diagnosis before bood test
Gulf War Illness	Rheumatoid Arthritis
Chronic Fatigue Syndrome	Lupus
Fibromyalgia	ALS
Multiple Chemical Sensitivity	MS
Other

18. Physician
Name
Address
Would you recommend to others Yes No

19. Date at onset - When symptoms first occurred

20. Residence at onset
City State/ProvinceCountry

21. Occupation at onset
Name of Company/Hospital/School

22.Health Before Onset
Perfect	Chemical Exposures
Good	Surgeries
Up & Down	Serious Diseases
Chronic Problems	Other

23. How Onset Began Slowly Rapidly After....
Flu	Surgery
Bronchitis	Head Injury
Pneumonia	Car Accident with Whiplash
Vaccination	Other

24. Date of Full Collapse when you could no longer work or attend school

25. Military
Gulf War Veteran	Boyfriend
Active Duty	Girlfriend
Reserves	Friends
National Guard	Relatives
Retired	Neighbors
Spouse	PX Shopping
Civilian who lived/worked on or near a base or weapons depot
Name of Base/Depot	Location

26. Native American
Lived/worked on or near a reservation
Name	Location

27. Prisons
Prisoner	Family
Guard	Worker
Lived Near
Name	Location

28. Others Infected
Spouse	Friend
Children	Neighbor
Mother	Co-Worker
Father	Dog
Brother	Cat
Sister	Other
Have they been tested Yes No
Results Pos Neg

29. Symptoms
Aching Joints	Noise/Motion Sensitivity
Chronic Fatigue	Temperature Sensitivity
Memory Loss	Sinusitis
Concentration Loss	Sore Throat
Depression	Suicidal Thoughts
Sleep Difficulties	Felt you Were Dying
Headaches	Unable to control anger/rage
Skin Rashes	Fevers
Muscle Spasms/Pain	Tinnitus
Tingling or Numbness in Extremities	Fibromyalgia
Nervousness/Anxiety/Panic Attacks	Hypoglycemia
Diarrhea	Irritable Bowel Syndrome
Breathing Problems/Asthma/Coughing	Swollen Glands in neck/armpit/groin
Chest/Heart Pain	Anemia
Dizziness	Toenail/foot fungus
Nausea	Blackouts
Stomach Pain	Spinal or Brain Encephalitis/Meningitis
Light Sensitivity	Weight Gain/Loss
Loss of Balance	Carpal Tunnel Syndrome
Hives	Bone Pain or Infection
Sex Problems	Kidney Problems
Urination Problems	Enlarged Liver/Spleen
Vision Problems	Adrenal Gland Failure
Hair Loss	Low Blood Pressure
Chemical Sensitivity	Reduced Sense of Smell
Medication Alcohol Intolerance	Other

30. Women Only
Irregular Menstrual Periods
Worse PMS/Cramps
Have you taken or are you currentlty taking
Estrogen Pills/Patches	Primrose Oil
Birth Control Pills

31. Current Treatment
Zithromax	Clindamycin
Doxycycline	Zagan (Sparfloxifin)
Ciprofloxacin	Dynabac
Levoquin	I.V. Antibiotic
Minocycline	I.V. Gamma Globulin
Other

32. Improvements From Treatment

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