ARACHNOIDITIS INFORMATION & SUPPORT

NEW  APPLICANTS, Please provide the following contact information and complete our survey below:

We are attempting to formulate profiles of arachnoiditis suffers with the information you provide. We realize some of the questions asked are of a personal, sensitive nature.  We ask that you complete as much information that you are comfortable in sharing.

Date of Birth

Male  Female

Please enter your primary-permanent e-mail address in the space provided below (This can NOT be hotmail, yahoo mail, or any other free e-mail address).

Please re-enter your primary-permanent e-mail address: We have lost new members because they have provided incorrect e-mail addresses and we have been unable to contact them.  Please make sure this address is correct.

Please enter the e-mail address you plan on using for group mail at YahooGroups in the space provided below (may be any e-mail address).

Please provide your Yahoo ID:

Have you ever had a myelogram?   Yes   No

If "Yes", how many myelograms did you have?  

Have you ever had spinal surgery?   Yes   No

 If "Yes", how many surgeries did you have?    

Have you ever had epidural steroid injections?   Yes No

If "Yes" how many epidural steroid injections did you have?  

On a scale of 1 to 10, what is your pain level right now?  

On a scale of 1 to 10, what is your average daily pain level?  

Have you been officially diagnosed with Arachnoiditis?   Yes No

If "Yes", when were you diagnosed with Arachnoiditis?   -- mm/dd/yy

I believe my Arachnoiditis was caused by:

My Arachnoiditis was caused by Surgery
My Arachnoiditis was caused by a Myelogram
My Arachnoiditis was caused by Epidural Steroid Injections
My Arachnoiditis was Caused by an injury
My Arachnoiditis was caused by something else, please explain:

Please tell us your Arachnoiditis story:

May we use your Arachnoiditis story on our webpage? (You will be provided another opportunity later if you would prefer to decide later)

Yes No

 

CONTINUE

 

 

 

Please review the information you provided below to assure it is accurate and correct.  If you find you have made a mistake, click the "Back" Link at the bottom of the review section.  This will take you back to the form where you can modify your replies. 

If all the information you have provided is correct and complete, please click on the "Submit Form" button below.  Your application will be processed and you will be presented with a confirmation page confirming your application is complete, with further information regarding your membership.

Name: NewMember_FullName
Street Address: NewMember_StreetAddress
Address (cont.): NewMember_Address2
City: NewMember_City
State/Province: NewMember_State
Zip/Postal Code: NewMember_ZipCode
Country: NewMember_Country

Home Phone: NewMember_HomePhone

Date of Birth: PersonalInfo_DateOfBirth

Personal Info: PersonalInfo_Sex

your permanent e-mail address is: PermEmailaddress

your YahooGroups e-mail address is: GroupeEmailaddress

your Yahoo ID: YahooID

Have you ever had a myelogram: Myelogram
How many myelograms did you have: NoMyelograms

Have you ever had spinal surgery: Surgey
How many surgeries did you have: NoSurgeries

Have you ever had epidural steroid injections: Epidural
How many epidural steroid injections did you have: NoEpidurals

On a scale of 1 to 10, what is your pain level right now: Painlevelnow
On a scale of 1 to 10, what is your average daily pain level: Avrgpainlevel

Have you been officially diagnosed with Arachnoiditis: Diagnosed
When were you diagnosed with Arachnoiditis: WhenDiagnosed

I believe my Arachnoiditis was caused by: Cause
My Arachnoiditis was caused by something else: CauseOther

Your Arachnoiditis story: MyStory

May we use your Arachnoiditis story on our webpage: UseMyStory

I need to modify my relies, go BACK to the input form

If all the information you have provided is correct and complete, please click on the "Submit Form" button below.  Your application will be processed and you will be presented with a confirmation page confirming your application is complete, with further information regarding your membership.

By submitting this membership application you agree to COFWA NETIQUETTE ACCEPTABLE USE GUIDELINES FOR GROUP POSTINGS