TI Symptoms, Medications, And Results
The purpose of the survey is to show that the TI population responds very, very differently than the non-TI population to medication; it should show that TIs are a distinct population set and not mentally ill. This survey is designed to log TI symptoms with the medication prescribed for the symptom and the results of taking the medication(s).
NOTE: AFTER SUBMITTING THIS FORM, YOU WILL HAVE THE OPTION TO MAKE MORE ENTRIES.
Please provide an anonymous email address
Take 5 minutes and create an anonymous gmail address to be used for this and future surveys or leave this blank. An email is preferred.
Your answer
Please select the TI symptom you were experiencing *
You will have the opportunity to select more symptoms.
If you chose "Other Symptom" in the previous question, please state what the symptom was and describe it.
Please limit your answer to one symptom. You will have the ability to enter in more.
Your answer
How severe was your symptom?
Minor Nuisance
Pure Torture
When did the symptom first start?
MM
/
DD
/
YYYY
How old were you when the symptom first started?
Your answer
How often did/do you experience the symptom?
If you chose "Other", please describe the frequency that you experienced the symptom.
Your answer
Please list the medication or medications that you were prescribed for the symptom, the dosage, and the time of day that you took them. *
Your answer
Did the medication(s) alleviate your symptom? *
If the medication worked most of the time but also had times where it failed to cure your symptoms, please describe the failed experiences.
Your answer
If you have any comments about the symptom, the medication, and the results, list them here.
Your answer
What was your age when you first started taking the medication?
Your answer
Approximate date you started taking the medication *
MM
/
DD
/
YYYY
Approximate date you stopped taking the medication *
MM
/
DD
/
YYYY
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