Chronic Illness Institute - life,health,family,workshops,patient,healthcare,professionals,condition,care,chronic,disease,organization

Please fill in the following to choose your FREE TIPS

* Name:
Company/Asso/Oranization (if applicable)
Postal Address
* Country:
* E-mail:
Cell/mobile:
* Tel: Home:
Tel: Work:

*These fields are compulsary

Please tick your chronic illness:
Please note that you can tick more than one

	Asthma
	Cancer
	Chronic Fatigue Syndrome (ME)
	Chronic Stress
	Depression
	Diabetes
	Endometriosis
	Fibromyalgia
	HIV/AIDS
	Heart attack and other heart related problems
	Illnesses which could be related to environmental change – New and emerging diseases such as (MRSA – found in many hospitals, SARS etc)
	Lupus
	Migraine
	Multiple Sclerosis (MS)
	Post-Traumatic Stress Disorder (PTSD)
	Recurring Malaria or Rickettsia
	Rheumatoid and osteoarthritis
	Stroke
	Tropical illnesses
	Viruses such as Epstein Barr, Coxsackie
Other:

Your Birthday:
Gender:	Male Female

Please tick the symptoms that you experience at present:
Please note that you can tick more than one

	Fatigue
	Stress
	Headaches
	Migraine
	Breathing difficulties
	Sweats
	Memory loss
	Concentration difficulties
	Depression
	Mood Swings
	Sleep Disturbances
	Muscle Pain
	Skin sensitive to touch
	Joint Pain
	Skin rashes
	Tremor
	Pins and needles or numbness in fingers and/or toes
	Numbness of the face
	Sore throat
	Swollen Glands
	Post Nasal Drip/Sinus
	Furry Tongue Feeling
	Sensitivity to light
	Ear – sensitivity or ringing (tinnitus)
	Poor body temperature control
	Dizziness – Loss of balance
	Visual disturbances
	Paralysis
	Chest pain/palpitations
	Abdominal/bowel disorder
	Nausea – occasional or continual
	Poor bladder control
	Bruising – easily or not
	Skin problems
	Paralysis
	Allergies
	Cold feet and hands
Other:

Does your partner or do any of your children or family members suffer with any chronic condition?
Yes No

Did you experience a trauma prior to becoming chronically ill? Yes No

Did you do any of the following prior to becoming ill? Work with chemicals, nuclear material? Yes No

Or work on a farm? (Please tick type)

Vegetables

Fruit

Cattle

Sheep

Pigs

Chickens

Travel to another city or country for business or holiday? Yes No

Care for any pet/bird/animal which was ill? Yes No

Use products to colour your hair? Yes No

Did you have a vaccination prior to developing your chronic illness? Yes No

Yes, please send me articles, information and further communications.

This information is intended only for residents of South Africa.
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