wAIHA Screener form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Please state your date of birth
*
-
Month
-
Day
Year
Date
Do you have documented confirmation of your wAIHA or ITP diagnosis that you are willing/able to provide?
*
Yes
No
Are you fluent in English (i.e., able to speak, read, write, and comprehend)?
*
Yes
No
Are you willing and able to participate in a 60-minute interview conducted over the phone or virtual web-enabled teleconference?
*
Yes
No
Following your diagnosis and start of treatment for wAIHA/ITP, have you ever had a period of time when you stopped receiving treatment?
*
Yes
No
If yes, did the effects of the treatment (i.e., reduction or alleviation of symptoms) continue for any period of time after the treatment was stopped?
*
Yes
No
Not sure
Optional feedback and/or comments. If you feel you would like to add anything else about your condition that may be relevant, feel free to do so here:
Submit
Should be Empty: