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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.
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Email
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Your email
Phone Number
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Your answer
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.
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Your answer
First Name:
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Your answer
Middle Name
Your answer
Last Name:
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Your answer
Birthdate
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MM
/
DD
/
YYYY
Birth Hospital
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Your answer
Birth City
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Your answer
Birth State
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Your answer
Birth Postal Code
Your answer
Your Mother's First Name
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Your answer
Your Mother's Middle Name
Your answer
Your Mother's Last Name
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Your answer
The name of your Mother's Doctor during her pregnancy with you:
Your answer
Please describe your birth deformities.
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Your answer
Please describe your current health issues.
Your answer
Your current Street Address
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Your answer
Your current City
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Your answer
Your current Postal Code
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Your answer
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