Morgellons Inquiry Survey

Please complete the following survey. All answers will be analyzed and the data will be made available to the medical and research community in the hopes that the identity of Morgellons will be made and a cure will be forth coming.

GENDER DATA

What sex are you?
Male
Female
  
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AGE DATA

What age group were you in when you first believe you were a victom of Morgellons?
1 - 5 years old
6 - 10 yeas old
11 - 16 years old
17 - 25 years old
25 - 34 years old
35 - 44 years old
45 - 54 years old
55 - 64 years old
65 - 74 years old
74 and up
  
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TIME LINE DATA

In what year did you contract Morgellons?
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
  
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GEOGRAPHIC DATA

If you reside in the United States of America, in which State or US Territory do you believe you contracted Morgellons in - Section 1?
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FEDERATED STATES OF MICRONESIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARSHALL ISLANDS
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
  
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If you reside in the United States of America, in which State or US Territory do you believe you contracted Morgellons in - Section 2?
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
  
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If you Live in Canada, what Province do you live in?
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEW BRUNSWICK
NEWFOUNDLAND AND LABRADOR
NORTHEN TERRITORIES
NOVA SCOTIA
ONTARIO
PRINCE EDWARD ISLAND
QUEBEC
YUKON
  
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MORGELLON SYMPTOMS

HEAD: Do you have any of the following symptoms? Multiple answers are accepted here.
Bumps
Lumps
Leisons
Channels
Headaches
  
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x
BRAIN AND PERSONALITY : Do you have any of the following symptoms? Multiple answers are accepted here.
Memory Loss - short term
Brain fog - groggy, unclear thinking
Thought processing becomes very taxing, difficult
Inability to focus or concentrate
Mood disorder
Libido - lack of
Loss of interest in things that normally interest you
Depression
Personality changes, like loss of creativity
Neurological symptoms, such as problems walking, clumsiness, speech problems
  
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x
HAIR: Do you have any of the following symptoms? Multiple answers are accepted here.
Hair appearance - stiff, brittle and dry
Hair loss
  
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x
EYES: Do you have any of the following symptoms? Multiple answers are accepted here.
Floaters on eye surface
Loss of visual acuity
Increase in discharge, often stringy
Sandy or gritty feeling in eyes
Eyes are sensitive to light
Eyesight is generally weakened
  
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X
EARS: Do you have any of the following symptoms? Multiple answers are accepted here.
Ears itch as motile fibers move inside
Ears ring or beep (but ears are clean)
Ears become clogged due to sinus drainage
Ears develop excess hair
  
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x
NOSE: Do you have any of the following symptoms? Multiple answers are accepted here.
Allergies or sinus - excessive congestion, mucus production
Mucus is thick, stringy, cohesive, dries into very hard substance
Scents do not smell correctly, may fluctuate from keen sniffing ability to no ability to smell
Nostrils develop excess hair
Nostrils develop very sore pimples
  
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X
MOUTH AND THROAT: Do you have any of the following symptoms? Multiple answers are accepted here.
Teeth become sensitive
Sore throat
Hacking cough
Constant sinus drainage
Glob of congestion always hanging at back of throat
Taste buds do not function correctly
  
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x
SKIN: Do you have any of the following symptoms? Multiple answers are accepted here.
Crawling feeling on the skin, like invisible bugs
Pinching, biting, stinging or prickling on the skin
esions - itchy, sore or painful, very slow-healing with no infection, sometimes containing "fuzz"
Open cuts or wounds - very slow healing with no infection, sometimes containing "fuzz"
Rashes - also appear where adhesive portion of Band-Aid is applied
Seed-like specks on the skin
Skin pigment changes (gets lighter or darker)
Skin texture - leathery, callus-like areas often where lesions had previously been located
Pimples - sore, long-lasting, can't squeeze out contents like a normal pimple
  
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x
BODY: Do you have any of the following symptoms? Multiple answers are accepted here.
Appetite decrease or increase
Weight loss or weight gain
Food cravings or total lack of interest in food
Gastrointestinal problems
Swelling or edema, including breast edema
Back ache - lower back
Back pain - neck and shoulder pain
Chronic fatigue
Weakness - strength diminishes
Bloating
Joint pain
Muscle twitching or cramping
Dizziness, disorientation, vertigo
Seizures
Blood pressure problems
eart races or beats irregularly for no apparent reason
Liver problems
Abnormal overheating
Excessive sweating
Cannot stay in sun for prolonged periods without becoming ill
Drastic body temp fluctuations
New, normal temp runs lower or higher than your previous "normal"
Bowel habits change, loss of muscle control
Stools contain foreign-looking matter
Urine has foreign-looking matter - seed like objects or puss
Pain that occurs simultaneously to untouched lesions on other parts of the body when leisons touched
Hardened splinter-like material beneath skin that is difficult to remove, extremely painful
Ingrown hair that is difficult to remove, extremely painful
Hair strands that are unusually thick or doesn't look like other hair
  
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BODY: Do you have any of the following symptoms? Multiple answers are accepted here.
Fingernails change shape or texture
Fiber or thread-like material emerging from the skin, or visible just beneath the skin
Lyme Disease shares overlapping symptoms and the borellia bacteria with Morgellons Disease
  
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x
Do you do any of the following on a regular basis? Multiple answers are accepted here.
Drink alcoholic beverages
Drink Beer
Drink Diet Drinks containing Aspartame
Smoke Cigarettes
Smoke Pipe
Smoke Cigars
Smoke Marijuana
Excessive use of prescription drugs
Use of illegal drugs including cocaine
  
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x
What type of job do you do?
Student
Office Worker
Factory Worker - Industrial
Factory Worker - exposed to chemicals and toxic waste
Farmer
Law Enforcement
Armed Services
Transport Driver
Medical Professional
Gardener
Fisherman - Industrial
Landscaper
Member of the Media
Medical Researcher
Other
  
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