BuiltWithNOF
Questioneer

Name:
Email Address:
State, Province or Country you live in.
Phone Number: (Not required)
Gender Male
Female
Have you been to a doctor about this condition? Yes
No
Please describe your experience in full detail. When did you first notice the problem? How long have you had it, etc.
Your age range:
Please check all that apply. Non-healing skin lesions
Itching
Biting
Bugs attacking you
Brain fog
Memory loss
Fatigue
Arthritic pain
Change in body tempature
Hair loss
Mood swings
Fiber balls on the skin
Weight loss or gain
Change in blood pressure
Glitter on skin
Loss of pigment with healed lesions
Diagnosis of fibromyalgia
Diagnosis of Lyme
Diagnosis of Sarcoidosis
Diagnosis of Lupus
Diagnosis of Lymphoma
None of the above
How many years have you been sick with this disease?
Additional information you wish for us to know about.
Please keep me updated on research and web sites about this disease.
Please share my info with others so that we may network.
I understand that the information given here will be kept confidential and will not be released unless I give written permission. Yes
Please upload photos that you have taken that you wish our experts to look at or that you wish to have published on our site. We will e-mail you and get written permission to publish anything you upload.
 

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