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Hyperemesis Education & Research
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Overview


NOTE: Please complete all the required fields (marked with a red *). Your answers are completely anonymous. This means that your answers will be viewed collectively as group data. Thank you for helping us with our research.

1.

* What country do you live in?

 
   

2.

* What is your current age?

 
   

3.

* What is your highest level of education?

 
   

4.

* How many times have you delivered/given birth? (Parity)

  times
   

5.

* How many times have you been pregnant? (Gravidity)

  times
   

6.

* How many times have you been pregnant AND experienced HG?

  times
   

7.

* What is your blood type?

 
   

8.

What specific treatments were sucessful in helping treat you for hyperemesis?

 
No medications
Acupuncture/Acupressure/Bowen
Antidepressant (Prozac, Wellbutrin, Zoloft)
Antihistamines (Benadryl, Gravol, Unisom)
Anti-motion sickness medications (Cyclizine, Dramamine, Dimenhydrinate, Meclizine)
Anzemet (Dolasetron)
(dosage if known)
Bed rest
Cannabis/Marijuana/Dronabinol/Marinol
(dosage if known)
Cisapride (Propulsid)
(dosage if known)
Compazine/Stemetil/Buccastem (Prochlorperazine)
(dosage if known)
Diclectin
(dosage if known)
Domperidone (Motilium)
(dosage if known)
Herbal Medicine
Homeopathics
Inapsine (Droperidol)
(dosage if known)
IV fluids
Kytril (Granisetron)
(dosage if known)
Maxolon/Reglan/Maxeran (Metoclopramide)
(dosage if known)
Methylprednisolone/Solu-Medrol (Steroids)
(dosage if known)
NG (Nasal to Stomach) Tube feedings
Pepcid (Famotidine)
(dosage if known)
Phenergan/Fenergan/Lergigan/Avomine (Promethazine)
(dosage if known)
Prevacid (Lansoprazole)
(dosage if known)
Scopolamine
(dosage if known)
SeaBands/Relief Bands
Tagamet (Cimetidine)
(dosage if known)
Thorazine (Chlorpromazine)
(dosage if known)
Tigan (Trimethobenzamide)
(dosage if known)
TPN/TPPN (Total IV Nutrition)
Vitamins (Pyridoxine, etc.)
Zantac (Ranitidine)
(dosage if known)
Zofran (Ondansetron)
(dosage if known)
Can't remember
Other (please specify as much info as possible):

     

9.

What was your health provider's attitude toward hyperemesis care and you?

 
Overall very supportive and helpful.
Eventually realized how sick I was and helped me.
Did not understand how sick I was.
Overall not sympathetic or caring.
 

Please comment on your healthcare provider's care:

 
   

10.

* How many times have you voluntarily terminated (aborted) due to HG? (excluding miscarriages)

 
None, didn't even consider it
None, felt too guilty even thinking about it
Almost did times
Voluntarily terminated (aborted) times
 
   

11.

What (if any) other reasons existed to lead you to terminate your pregnancy?

 
Baby died due to complications/treatment of HG.
Emotional stress. (Depression, Anxiety, Trauma)
Feared baby would be abnormal due to HG or treatment.
Feared self or baby would die.
HG recurred, was told it would not.
Lack of confidence in medical care or doctor.
Medically necessary - NOT related to HG (please specify reason):

No treatments offered.
Non-HG. (unplanned, genetic syndrome, etc.)
Treatments ineffective or not tolerated.
Unable to care for family and/or self.
Unable to work, may lose job.
Very sick and miserable, no hope for relief.
Other reasons (please specify):

   

12.

* How has your life or future plans changed after experiencing hyperemesis? Any suggestions for others?

 
   

13.

* What is your e-mail address? (CONFIDENTIAL, only used to avoid duplicates. Your e-mail will NEVER be used to contact you unless you request us to do so below.)

 
(e.g.: yourname@host.com)
 
Please contact me via e-mail if it is neccessary to clarify or get more information?
   
 

Updated on: Apr. 05, 2009

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