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Case Info Questionnaire

We receive many e-mails from our site visitors regarding specific questions about their particular situation with HG. In order for us to best answer your questions, it is helpful to know some general information about your present situation and past medical history. This information is not used in any other manner or kept on file. Please answer appropriate questions to the extent you are comfortable. This will help us respond more quickly and thoroughly.

Thank you and we look forward to talking with you! One of our health professionals usually responds within 1 business day or less, depending on the volume of e-mail we receive.

About Your Pregnancy:
1)	Are you pregnant with HG for the first time?
	Yes No
2)	How many weeks into your pregnancy are you?
	weeks.
3)	When do you plan to become pregnant?
4)	When did you terminate your pregnancy?
About Your Weight Change:
1)	How much weight have you lost?
	Lbs. Kgs.
2)	Were you over or under weight at conception?
	Over my normal weight Under my normal weight
3)	Have you consulted with a nutritionist?
	Yes No
4)	What was your weight before pregnancy?
	Lbs. Kgs. St.
About Your Nutrition/Treatments:
1)	Are you on TPN/TPPN?
	Yes No
2)	What foods can you eat or NOT eat?
3)	How many times are you vomiting each day?
	times per day.
4)	Have you had a NG or PEG inserted?
	Yes No
5)	Current Medications & dose (mg) per day:
6)	Have you been hospitalized?
	Yes No
About Your Health Issues:
1)	Do you have any other health issues?
	Yes No
2)	Do you have any thyroid dysfunctions or stomach ulcers?
	Yes No
3)	What other illnesses have you been tested for related to HG?
About Your Concerns:
1)	What is your greatest concern?
2)	Were you able to read the info on our site?
3)	Who is helping you at home (partner, home health, etc.?
4)	Are you curently employed full time?
	Yes No
* 5)	Enter your specific question and/or additional info in the space provided below: *
How can we get in touch with you?
	* Name: * E-Mail: (e.g.: yourname@domain.com) PLEASE CONFIRM YOUR E-MAIL ADDRESS. We have been unable to respond to several e-mails due to incorrect addresses. Phone: Fax: Mobile: Time Zone: (e.g.: U.S. Central Standard Time)
* Security Code	(Please enter the letters and numbers you see in the image above.)

 

Updated on: Mar. 26, 2015

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