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We need help catching a killer.

     No, we are not the police. We are the online ARDS
     Support Group. Just as detectives require evidence to
     catch killers, the medical community requires
     statistical research to help corner killer diseases to
     help eradicate them. A solid, concise database of both
     victims and survivors, as well as circumstances
     involved in their contracting ARDS will be invaluable
     to medical researchers in their quest to end the
     suffering caused by this deadly syndrome.

     Won't you please help?

Name

Street Address

City

State

Zip Code

Telephone Number

Email Address

Please select one below

A) Are you an ARDS survivor?

B) Are you family or a friend of an ARDS survivor?

C) Have you lost a loved one to ARDS?

The following questions pertain to the ARDS patient.

Patient Age

Sex of Patient
Male
Female

Condition Pre-ARDS? What was the patients health condition pre-ards

How long before ARDS developed?

Duration of ARDS crisis?

Initial condition Post-ARDS?

Current condition Post-ARDS?

Post ARDS problems if any?

1.) Prior to ARDS, did the patient have a history of Diabetes? If you answered yes, please indicate what type.

Yes
No

2.) Does the patient suffer from Diabetes post-ARDS? If you answered yes, please indicate what type.

Yes
No

Additional Comments:

This release hereby authorizes ARDS Support Center, Inc., or their agents, to examine, make copies of, and/or share any and all medical information with the ARDS Support Center Board of Medical Advisors that I have supplied on this questionnaire.

Agree

Disagree

Type Full Name Here

Thank you for helping in our research efforts.