Survey of Firebreathing Practices

We understand that firebreathing is an ancient art still practiced and learned in myriad forms. We would like to better understand these approaches and their potential complications and ask you to help us. To help us do this, please participate in this research study by completing this questionnaire on Firebreathing Practices. We intend to look at how common different practices are, how they were learned, and if they have an influence on performer health. Participation in this study is completely voluntary and the information collected will be kept anonymous - this means that your name and other identifying information is not required. This information may be used for future publication. You can refuse to participate and such a decision will not affect your future as either a firebreather or as a patient. If you have additional questions, please contact Dr. Jennifer Rosen of Boston Medical Center at 617-414-8016. This survey should take about ten minutes to complete. You may stop taking the survey at any time and return to it at a future visit, and you may also choose not to answer any questions within the survey.

	0	1	2	3	4	5	>5
a)How many times did you visit your primary care physician (general practitioner)?	In the past twelve months (please check one answer per row) a)How many times did you visit your primary care physician (general practitioner)? 0	1	2	3	4	5	>5
b)How many times were you admitted to the hospital?	b)How many times were you admitted to the hospital? 0	1	2	3	4	5	>5
c)How many surgical procedures have you had?	c)How many surgical procedures have you had? 0	1	2	3	4	5	>5

	Yes	No
a)Heart (angina, heart attack, palpitations)	Have you ever had any symptoms related to: (Please check one answer per row) a)Heart (angina, heart attack, palpitations) Yes	No
b)Lung (bronchitis, asthma, allergies, emphysema)	b)Lung (bronchitis, asthma, allergies, emphysema) Yes	No
c)Gastrointestinal (colitis, constipation, irritable bowels)	c)Gastrointestinal (colitis, constipation, irritable bowels) Yes	No
d)Neurological (anxiety, depression, back pain, sleeplessness)	d)Neurological (anxiety, depression, back pain, sleeplessness) Yes	No
e)Urinary (incontinence, frequency)	e)Urinary (incontinence, frequency) Yes	No

	Yes	No
Sore throat	Have you had any of the following symptoms? (Please check one answer per row) Sore throat Yes	No
Heartburn	Heartburn Yes	No
Acid reflux	Acid reflux Yes	No
Hiatal Hernia	Hiatal Hernia Yes	No
Stomach Ulcer	Stomach Ulcer Yes	No
Pleurisy/Pneumonia	Pleurisy/Pneumonia Yes	No
Dysphagia	Dysphagia Yes	No
Burns	Burns Yes	No

1. Health Status

1. How do you rate your health?

2. Do you have a primary care physician?

3. Please state the three health problems that bother you the most.

4. In the past twelve months (please check one answer per row)

5. Were any of these surgical procedures or visits related to your firebreathing?

6. Have you ever had any symptoms related to: (Please check one answer per row)

7. Have you had any of the following symptoms? (Please check one answer per row)

8. Have you ever been diagnosed with any form of cancer?

9. If you answered yes to question #8, what type of treatment did you receive?

10. If you answered yes to question #8, do you feel that this was related to your firebreathing and how?

Please state the three health problems that bother you the most. a)
b)
c)