Patient clinical information
GGU submission form 2
Email address *
Insert anonymized patient code *
The same as in GGU submission form 1
Your answer
Main diagnosis *
Date of first diagnosis *
MM
/
DD
/
YYYY
Additional diagnosis
Date of additional diagnosis *
MM
/
DD
/
YYYY
Infection profile *
Recurrent
Sporadic
No
Unknown
Bacterial
Viral
Fungal
Parasitic
Specify species
EBV
HIV
HSV
HPV
CMV
Zoster
Staphylococcus
Streptococcus
Salmonella
E. coli
Candida
Sporadic
Recurrent
Chronic
Immunoglobulins *
Absent/reduced
Increased
Normal
Unknown
IgA
IgE
IgG
IgM
Vaccination responses *
Absent/reduced
Positive
Not tested
Tetanus toxoid
Diphtheria toxoid
Pneumococcal polysaccharides
B lymphocytes *
Reduced
Increased
Normal
Unknown
Immature
Switched-memory
Marginal zone
Transitional
T CD4 lymphocytes *
Reduced
Increased
Normal
Unknown
Naive
Central memory
Effector memory
Memory
Regulatory
T CD8 lymphocytes *
Reduced
Increased
Normal
Unknown
Naive
Memory
Additional signs and symptoms - 1
Select one
Approximate date of first presentation - 1
MM
/
DD
/
YYYY
Additional signs and symptoms - 2
Select one
Approximate date of first presentation - 2
MM
/
DD
/
YYYY
Additional signs and symptoms - 3
Select one
Approximate date of first presentation - 3
MM
/
DD
/
YYYY
Additional signs and symptoms - 4
Select one
Approximate date of first presentation - 4
MM
/
DD
/
YYYY
Additional signs and symptoms - 5
Select one
Approximate date of first presentation - 5
MM
/
DD
/
YYYY
Additional comments
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy