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Pregnancy and Diamox Information Request

This information is necessary since we tailor each study packet to your particular pregnancy history. After we receive your Information Request, we will send the study packet to you by U.S. mail.

• required fields

Today's Date

Title (Mr. Ms. Dr.)

• First Name

• Last Name

• Primary Telephone Number

• Email

• Mailing Address

Address - Appt. No. - Other

• City

• State | Province

• Zip Code

• Country

1. Were you pregnant at the time of your diagnosis of intracranial hypertension (IH) or have you been pregnant since your diagnosis?

Yes, go to question # 2.
No, submit survey.

2. Have you taken Diamox during a pregnancy or multiple pregnancies?

Yes, go to question # 3
No, submit survey.

3. Number of pregnancies in which you took Diamox?

4. Did you take Diamox at any time during the first 19 weeks of any pregnancy?

Yes
No

If Yes, indicate trimester(s):

1st Trimester (1-12th week)
2nd Trimester (13-19th week)

5. Did you take Diamox after the 19th week (i.e., from 20th week to birth)?

Yes
No

6. How many total live births have you had since being diagnosed with IH?

7. Total number of pregnancies at or since the time of your diagnosis:

8. How old are your children from these pregnancies?