Symptom Questionnaire Survey

Question Title

* 2. Symptoms include history of or current problems with nonhealing cracks/fissures at the corners of the lips (cheilitis).

Yes

Unknown

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* 3. Symptoms include history of or current problems with overall skin dryness and/or pruritus - peeling skin on the palms and soles, and fingertip fissuring.

Yes

Moderate

Unknown

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* 4. Symptoms include history of or current problems with thinning hair and/or hair loss without scarring (Telogen effluvium).

Yes

Moderate

Unknown

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* 5. Symptoms include bone spurs, calcinosis (calcium deposits in the skin and subcutaneous tissue), and/or hypercalcemia. Over the long term osteoporosis and hip fractures may be a concern.

Yes

Unknown

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* 6. Symptoms may include headache, nausea, and vomiting.

Yes

Headache

Nausea and/or vomiting

Unknown

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* 7. Symptoms of increased pressure around the brain may be a cause of severe headaches and/or may affect vision, narrowing of the field of view, (pseudotumor cerebri syndrome).

Yes

Unknown

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* 8. Symptoms include hypothyroidism, or intermittent problems with thyroid function. Undiagnosed issues of low thyroid function might include thinning hair, feeling cold easily, depression, apathy, gaining excess weight easily, feeling very tired easily, constipation.

Yes

Unknown

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* 9. Symptoms include hypertriglyceridemia and other blood lipid changes.

Yes

Unknown

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* 10. Symptoms include a history or current problem of acute hemorrhagic pancreatitis.

Yes

Unknown

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* 11. Symptoms include history of or current renal/kidney dysfunction.

Yes

Unknown

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* 12. Symptoms include history of or current problems of elevated serum transaminases, or chronically with liver damage leading to fibrosis and hepatic stellate cell activation.

Yes

Unknown

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* 13. Symptoms include mental confusion, irritability, anxiety, depression, and/or suicidal ideation, and/or more extreme psychosis or suicide attempts.

Anxiety

Depression

Irritability/agitation/confusion

Irrational thinking/Psychosis

Suicidal ideation

Suicidal attempt

Suicide, form being completed for the patient

None of the above

Unknown

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* 14. Symptoms include mitochondrial dysfunction and/or oxidative stress (symptoms might include fatigue, muscle cramps, fibromyalgia).

Yes

Unknown

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* 15. Symptoms include increased β-amyloid1-40 peptide (the protein tangles that may be elevated in the brain of patients with Alzheimer's dementia or sometimes in autism).

Yes

Unknown

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* 16. Symptoms include dopamine imbalance and may include low dopamine: "tremor, stiffness, slowness of spontaneous movement, poor balance, and poor coordination"; and/or elevated dopamine: "high libido (sex drive), anxiety, difficulty sleeping, increased energy, mania, stress, and improved ability to focus and learn" and muscle twitches may occur.

Symptoms of low dopamine.

Symptoms of elevated dopamine.

Symptoms may include both types of problems at different times.

No symptoms of dopamine imbalance.

Unknown

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* 17. I (or the patient) have had a history of psychiatric or other medication use.

Retinoid medication, such as bexarotene, isotretinoin, etretinate, and acitretin

Unknown

Other Medication history (please specify)

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* 18. Akathisia symptoms have been a problem (repetitive motions, largely uncontrollable, may also have mental symptoms of anxiety or agitation).

Yes

Unknown

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* 19. Mast Cell Activation Syndrome or histamine excess has been a problem (seasonal allergy or allergy like symptoms and food intolerances somewhat frequently).

Yes

Unknown

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* 20. I (or the patient) have had a history of an adverse vaccine reaction.

Yes

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* 21. Has there been a history of a viral or other type of infection with chronic stages such as Lyme's Disease, Epstein Barr virus, or SARS-CoV-2 (COVID19)?

Yes

Unknown

Infection history (please specify)

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* 22. Meals and snacks include meats, poultry, fish, milk and other dairy products.

Several servings per day typically

At least one serving per day

At least one serving per week

One serving per month or less

No servings of animal products typically

Unknown

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* 23. Meals and snacks include carrots, tomato products (fresh, or tomato sauce, ketchup, or salsa), sweet potatoes, winter squash or pumpkin, dark green leafy vegetables, cantaloupe, apricots, mango, papaya, peaches, nectarines.

Several servings per day typically.

At least one serving every other day

At least one serving per week

One serving or less per month

No servings of carotenoid rich plant foods typically

Unknown

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* 24. Vitamin A and/or Beta-carotene is taken as a supplement singly or in one-a-day vitamins daily.

Yes

Weekly

Monthly

Unknown

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* 25. Retinoid toxicity - excess of the active form of vitamin A - has been identified with retinoid medication treatment. Stopping retinoid medication use helps. Theoretically liver injury may cause an increase in vitamin A being activated in the liver & lead to toxicity symptoms also. Reducing vitamin A in the diet or supplements may be needed. Whether that is true and how to heal the liver so less vitamin A is activated would be a question for more research. Thanks for participating in this early stage of information gathering.

I was familiar with the symptoms of retinoid toxicity.

I was not familiar with the symptoms of retinoid toxicity.

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* 26. Demographic information: What is your genetic sex (or the patient's)?

Male

Female

Prefer not to answer.

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* 27. What is your gender (or the patient's)?

Male

Female

Nonbinary

Asexual

Prefer not to answer.

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* 28. What is your age (or the patient's age)?

17 or younger

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 29. What is your (or the patient's) race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Another race or ethnicity, please describe below

Self-describe below:

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* 30. This survey is being completed about your own symptoms or on behalf of someone else? Thank you very much for participating in this survey.

Survey answers are about myself

Survey answers are about my child.

Survey answers are about a patient.

Survey answers are about a deceased person.

Survey answers are about a friend or some other person being helped. Thank you!

Symptom Questionnaire

Question Title

* 1. Is dry skin, eyes, and/or mucus membranes a frequent symptom?

Question Title

* 2. Symptoms include history of or current problems with nonhealing cracks/fissures at the corners of the lips (cheilitis).

Question Title

* 3. Symptoms include history of or current problems with overall skin dryness and/or pruritus - peeling skin on the palms and soles, and fingertip fissuring.

Question Title

* 4. Symptoms include history of or current problems with thinning hair and/or hair loss without scarring (Telogen effluvium).

Question Title

* 5. Symptoms include bone spurs, calcinosis (calcium deposits in the skin and subcutaneous tissue), and/or hypercalcemia. Over the long term osteoporosis and hip fractures may be a concern.

Question Title

* 6. Symptoms may include headache, nausea, and vomiting.

Question Title

* 7. Symptoms of increased pressure around the brain may be a cause of severe headaches and/or may affect vision, narrowing of the field of view, (pseudotumor cerebri syndrome).

Question Title

* 8. Symptoms include hypothyroidism, or intermittent problems with thyroid function. Undiagnosed issues of low thyroid function might include thinning hair, feeling cold easily, depression, apathy, gaining excess weight easily, feeling very tired easily, constipation.

Question Title

* 9. Symptoms include hypertriglyceridemia and other blood lipid changes.

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* 10. Symptoms include a history or current problem of acute hemorrhagic pancreatitis.

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* 11. Symptoms include history of or current renal/kidney dysfunction.

Question Title

* 12. Symptoms include history of or current problems of elevated serum transaminases, or chronically with liver damage leading to fibrosis and hepatic stellate cell activation.

Question Title

* 13. Symptoms include mental confusion, irritability, anxiety, depression, and/or suicidal ideation, and/or more extreme psychosis or suicide attempts.

Question Title

* 14. Symptoms include mitochondrial dysfunction and/or oxidative stress (symptoms might include fatigue, muscle cramps, fibromyalgia).

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* 15. Symptoms include increased β-amyloid1-40 peptide (the protein tangles that may be elevated in the brain of patients with Alzheimer's dementia or sometimes in autism).

Question Title

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* 17. I (or the patient) have had a history of psychiatric or other medication use.

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* 18. Akathisia symptoms have been a problem (repetitive motions, largely uncontrollable, may also have mental symptoms of anxiety or agitation).

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* 19. Mast Cell Activation Syndrome or histamine excess has been a problem (seasonal allergy or allergy like symptoms and food intolerances somewhat frequently).

Question Title

* 20. I (or the patient) have had a history of an adverse vaccine reaction.

Question Title

* 21. Has there been a history of a viral or other type of infection with chronic stages such as Lyme's Disease, Epstein Barr virus, or SARS-CoV-2 (COVID19)?

Question Title

* 22. Meals and snacks include meats, poultry, fish, milk and other dairy products.

Question Title

* 23. Meals and snacks include carrots, tomato products (fresh, or tomato sauce, ketchup, or salsa), sweet potatoes, winter squash or pumpkin, dark green leafy vegetables, cantaloupe, apricots, mango, papaya, peaches, nectarines.

Question Title

* 24. Vitamin A and/or Beta-carotene is taken as a supplement singly or in one-a-day vitamins daily.

Question Title

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* 26. Demographic information: What is your genetic sex (or the patient's)?

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* 27. What is your gender (or the patient's)?

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* 28. What is your age (or the patient's age)?

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* 29. What is your (or the patient's) race or ethnicity?

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* 30. This survey is being completed about your own symptoms or on behalf of someone else? Thank you very much for participating in this survey.