DCPN Survey Form

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DCPN Survey Form

Survey questions on your experience with Peripheral Neuropathy (PN).
Sponsored by the DC Metro Peripheral Neuropathy Support Group (DCPN)
Website: http://dcpnsupport.webs.com/

Survey responses are anonymous. There is no identification information requested or recorded (no names, IP addresses, email addresses or any other information that could identify the respondent).

The data collected will be summarized and used to help support and educate our group members.
We may post summary results on our website (if the group approves and there is enough data to be useful)
We may, eventually, share the raw, anonymous data with medical researchers or analysts (if the group approves)

There are 26 questions, including a few follow-on questions that are asked depending on your answers.
All questions are optional (Except for 2 follow-on questions)

1/26 Personal Code Word (optional)

This first question is an arbitrary word or phrase (NOT YOUR REAL NAME!) that can be used to allow YOU to change/correct/delete your entries. If we get another entry with that same Code Word we will (by hand, for now) delete the first response and, instead, use the second one. Without a Code Word, we cannot match old and new entries to do this. (15 character limit; Please: no special characters)

If you gave us a Code Word, now would be a good point to pause, write it down and save it. We will not find it for you later; that would defeat our desire to keep your entry anonymous, even from us.

NOTE: we may, in the future, require people using this survey to get and use a GMAIL account to fill in the survey. That still keeps the survey anonymous (since the gmail address is not recorded on the results) , but would not require remembering a special code word (which is, essentially, a password)

2/26 Have you been to DCPN meetings?

Yes

No (if you want to come, please check out our website for directions and meeting dates)

Clear selection

3/26 How long have you had PN (as far as you know)

a. Less than one year

b. 1-5 years

c. 6-10 years

d. more than 10 years

Clear selection

4/26 What is the cause of your PN? (if more than one, use Other)

Diabetes

Pre-Diabetes (Insulin Resistance)

Chemotherapy

HIV/AIDS

Alcoholism

Surgery/Medical procedure

Idiopathic (we don't know)

Other:

Clear selection

Clear form

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