Dercum's disease (Adiposis Dolorosa) Questionnaire

Please fill out this questionnaire if you are so inclined.  I am doing my own research as I do not see any doctors doing it.  Thanks.  NOTE:  Make sure that the URL for this page DOES NOT have a squiggle in it, (i.e., it does not look like: /~Dercums_Data).  If it does, go to this page (same questionnaire) before you start filling in the blanks.  Thanks! 

NOTE TO TRAVEL SPAMMER -- Please stop. You fill up the buffer space and no one can fill out the questionnaire. And NO ONE sees the URLs. Thanks.

One recent oddity has been seen -- if, after filling out and submitting the questionnaire, you get an error that says:

FrontPage Error.

User: please report details to this site's webmaster.

Webmaster: please see the server's system log for more details.

Don't get upset. 

Your answers did get registered, and I can get access the answers.  If you want confirmation, send me an e-mail.  If it does something else, tell me what it did ;-)  I'm sorry for all this hassle, but the problem seems to be that I have an old copy of Microsoft FrontPage (web publisher).

First Name:  Last Name: 

e-mail address:  (don't forget the "@")


City:    State: 

Country:      Postal code:


Sex:  Female Male               Age:

-----Start of the questions-------

Yes No    Do you have arthritis or arthritis type disease or symptoms.


Yes No    Chemical sensitivities


Yes No    Sugar metabolism problems


Yes No    Hormonal difficulties - menstrual history, pregnancies, etc.


Yes No    Other hormonal difficulties


Yes No    Food allergies or sensitivities


Yes No    Any family members with same or similar symptoms


Yes No    Circulatory problems


Yes No    Anemias


Yes No    Sweating


Yes No    Dehydration


Yes No    Itchiness


Yes No    Swelling in joints


Yes No    Weakness


Yes No    Loss of memory


Yes No    Body temperature abnormalities - too hot or too cold


Yes No    Digestive disturbances


Yes No    Stabbing pains


Yes No    Dental problems (sensitivity to the filling material?, other)


Yes No    Do you have tumors?

When did tumors begin? 

Where are they located? 


If they are sensitive to:  Touch, Pressure, Sound, Light, Other:


If they are better or worse with periods (women only), or if there a
cyclical quality to the tumors erupting, getting bigger, smaller, itching, etc.

Describe Variability:     

Are the Tumors diffuse or encapsulated or both (different in various regions?)

What type in which region?

Yes No    Drug Allergies?


Yes No    Steroid use?

Yes No    DHEA ingestion?

Yes No    Do you suffer from yeast infections?

Yes No    Have you ever had shingles?

Other comments:

Nedstat Counter
Version 1.02

Come and Join the Dercum Mailing list.
Be kept informed of any late breaking news!

 Join Dercum! 

Return to Dercum's Disease Home Page

Last updated 15 June 2007

Comments about the web page format
should be sent to the Don

The information submitted on this form will remain confidential.  It will be used to develop anonymous trend data concerning this disease which can be passed on to interested doctors.  If more personal data is needed, you will be asked if you are willing share your identity .   Furthermore, please don't forget that the information provided on this site is designed to support, not replace, the relationship that exists between a patient and her or his physician.