Join IPPSO Today



If you want to get all the latest IPPSO medical news, information about PPS and polio from around the world, or become a volunteer, please fill out the below form.

All information is confidential to IPPSO. Names, addresses, e-mail addresses and other information that may reveal your identity are not for public information, unless you grant permission as an individual. Any information about your PPS symptoms used for research into Post-Polio Syndrome will remain anonymous. This is not a scientific survey, however, nor do we claim it to be.

This form is an effort to accumulate as much information as possible about our family and polio survivors around the world, their illness and assist in research as the need may arise. We ask that you complete this form and submit it to us.

We understand that it might take a little of your time to complete it and we apologize for any inconvenience, but the more information we can ascertain, the more we are able to assist our members and the general public about polio/PPS. Thank you for your time and effort in completing the form.

In order to help us meet our financial obligations we would ask that you consider making an annual $20.00 donation. Anything beyond that would be of great benefit to many. You can send your check or money order made out to IPPSO to:

IPPSO
c/o Kathy Husmann
423 First Avenue South
Hibbing, MN 55746
(You will receive a receipt).

Alternatively, you can use our PayPal account by clicking here, and then click the 'Make a donation' button on the page that then opens. It is fast, free and secure, and convenient, as you do not need to do anything else than filling out a form! It is also tax deductible as we are a 501 (c) 3 non-profit organization.

Please fill out any information that pertains to you and be sure to highlight your answer on mutiple-choice questions.

The items marked with an asterisk (*) are required information.

PERSONAL INFORMATION:

*Name (first & last)
*Street Address 1
Street Address 2
*E-mail Address
*City
*State
*Country
*Zip Code
*Phone Number
*Birthday (mm/dd/yyyy) DOB Age Gender
How many languages do you speak? Which?
Yahoo Name if you have one?
Yahoo Nickname
IPPSO Bulletin Board/Chat-room Nickname
*What kind of email do you want to receive from IPPSO?
*May we release your e-mail to our members only for introduction purposes? Yes No
*Emergency name/contact person:

*Address:
*Phone:
*Relationship:




Would you like a PEN PAL? Yes No

MEDICAL QUESTIONNAIRE

*Did you have Polio? Yes No Unknown
What year did you have polio? (yyyy)
What City & State did you contract Polio in?
Did you have Bulbar Polio or Spinal Polio?
*Did you have Paralytic or Non-Paralytic Polio?
Please indicate what part of your body was most affected? (whole body, left side of body, right side of body, upper torso-left side, upper torso-right side, left leg, right leg, left arm, right arm, left foot, right foot, face)
What hospital were you in, if any? (Please provide City and State)
What type of treatment were you given, if any?
*What if any appliances and/or assistive devices do you use?
*Did you receive the Salk or Sabin Vaccine?
*Were you a poster child? Yes No
If yes, for what organization?
*Have you been able to obtain your medical records? Yes No Haven't tried
Do you have a weight problem? Yes No
Have you found physical exercise beneficial to you? Yes No Haven't tried
Can you do any physical exercise? Yes No Haven't tried
*Are you presently suffering from PPS? Yes No Unknown
Do you suffer from any other illness? (Please list all other illnesses and dates if possible)
What specific PPS medication are you taking?
What other medications are you taking for other medical problems, please specify.
Does the medication for PPS help your PPS symptoms? Yes No Unknown
List any surgery and year of surgery (yyyy) whether or not they were due to polio.
*On average, is your pain: Level 1: You experience very minor pain in parts of your body. You don't have to take any pain medications and you can do your work with no problems.
Level 2: The minor pain has increased to dull aches in some parts of your body. You don't have to take medication and you still can work as usual but you don't want people 'in your face'!
Level 3: Your minor pain is strong enough to get your attention. You resort to Over the Counter medications. You are getting grouchy now.
Level 4: Now you can only ignore the pain if you are involved in activities at work or home. You are taking more Over the Counter medications but they don't last long. You begin to cut back on your activities in favor of just sitting down.
Level 5: You can't ignore this pain for more than an hour, even with Over the Counter Medications. You cut back of all activities except the most important ones. Work is possible, just barely.
Level 6: You simply can not IGNORE your pain for even a few minutes. But with prescription pain medications you have limited functioning abilities.
Level 7: This level of pain is the kind that keeps you awake at night, makes it hard to think and act. Your prescription medication only dulls the pain for a short time. You limit your activities in order of importance. You really can't work well.
Level 8: This is serious pain. You don't want to do anything or be bothered by anyone. You have taken so much pain medication you are unable to fully concentrate on anything. Work is out of the question.
Level 9: Very serious pain here. You can not concentrate on anything but pain. You should not do business transactions or make any important decisions because of your limited mental state. You might want to give someone Power of Attorney. You can not go to work and you shouldn't drive a car. At this point you begin withdrawing from the world around you.
Level 10: Pain has made you totally unable to function. You don't want to deal with or talk to anyone. Even with narcotic pain medications you are still in horrible pain. You go to bed or go to the emergency room for any help you can get.

Source: Carol Johnson http://www.angelfire.com/ia/cjmachine/pain.html
*Are you presently seeing a physician for PPS? Yes No
If yes, please list, their name, address and phone number.
Did you have to stop working because of PPS? Yes No
*If you worked or are still working, what type of work did/do you perform?
*Do you need help getting Social Security Disability Benefits?  Yes No Haven't tried
In your opinion, does the medical profession adequately treat PPS? Yes No
*Are you looking for someone to communicate with about PPS? Yes No
Has it been hard for you to accept the fact that you have PPS? Yes No
Is your family able to cope with your illness? Yes No
Have you been able to access your community businesses/buildings easily? Yes No
*Have you ever had a reaction to anesthesia? If yes, please explain
Yes No

*Have your children shown any medical problems? Yes No

*Did any other family members get Polio? Who, age, sex - Please ADD YEAR!!! (yyyy) Yes No

*Are their any areas of support you would like IPPSO to help you with immediately? Yes No
If yes, please indicate here:

Additional Comments:

 

 

MEMBER AND VOLUNTEER INFORMATION:

Please check the checkbox that applies to you.

I want to vounteer
I can donate this many hours
I am available on these days
Anything I can do to help - Tell us in the comments what you would like to do
Membership/Welcome Committee - Send welcome letters to new members
Research - Surf for Polio and/or PPS info & obtain reprint authorization from those sites and sources
Fundraising - Help with raising funds and organize auctions for members
Grant submission - If you check this box, you guarantee you have prior experience in this area
Website assistance - Basic HTML knowledge needed

Additional Comments for other things you may do:

 

DONATION INFORMATION:

This section is for you who are interested in donating money to IPPSO.
Thank you for your support!

Amount of Donation
Contact Person
Equipment Donation (specify) Wherever it is needed
Office Administration
To purchase adaptive equipment
Fundraising
Media/Public Relations
Membership
Other(Please Specify below)



  

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