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* 1. Patient's Name:

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* 4. At what email address would you like to be contacted?

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* 5. What is your gender?

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* 6. Please describe your race/ethnicity.

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* 7. Did patient survive?

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* 8. Were you diagnosed by a physician with DRESS Syndrome?

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* 9. In what month and year did you first become ill with DRESS Syndrome?

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* 10. Were you hospitalized?

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* 11. What drug(s) is believed to have induced your DRESS Syndrome?

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* 12. Were you tested for HHV-6 (human herpes virus 6) viral reactivation?

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* 13. Was your HHV-6 test positive for reactivation?

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* 14. Are you still being treated for your symptoms with steroids or other medications? Please specify.

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* 15. Do you have any short or long term complications from DRESS Syndrome such as thyroiditis, auto-immune disease, diabetes, Graves' disease or other? Please specify.

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* 16. Would you be interested in participating in a genetic research study on DRESS Syndrome?

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