American Thalidomide Survivor Survey
Please fill in this survey and submit for yourself or a relative or friend American thalidomide survivor.

This is part of a study to determine the real extent of thalidomide damage in the United States.

Be counted!

Thank you for your participation.

Phone Number *
If you are submitting this survey on behalf of an American thalidomide survivor, please describe your relationship and specify your contact info(name, email and phone) for follow up. *
First Name: *
Middle Name
Last Name: *
Birthdate *
MM
/
DD
/
YYYY
Birth Hospital *
Birth City *
Birth State *
Birth Postal Code
Your Mother's First Name *
Your Mother's Middle Name
Your Mother's Last Name *
The name of your Mother's Doctor during her pregnancy with you:
Please describe your birth deformities. *
Please describe your current health issues.
Your current Street Address *
Your current City *
Your current Postal Code *
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This form was created inside of US Thalidomide Survivors.