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State:	-- Outside the United States AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming
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	month	day	year
Date of Birth:	-- January February March April May June July August September October November December	-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	-- 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Gender:	-- Female Male

	month	year
When did you first notice symptoms?:	-- January February March April May June July August September October November December	-- 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
What geographic region do you associate with the onset of your symptoms?	-- Outside the United States AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming Outside the United States

	Yes	No
Does anyone else in your home have this condition?
Have you sought medical assistance?
If yes, number of physicians consulted: -- 1 2 3 4 5 6 7 8 9 10 More than 10

Please check if you have experienced the following symptoms:

	Yes	No
Biting or Stinging
Black Specks
Crawling Sensation
Fibers or Fuzzy Artifacts
Itching
Lumps on Head
Salt-like Crystals
Scaling Skin
Scarring
Skin Discoloration
Sores or Lesions

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