SURVEY

PINK DISEASE is babyhood mercury poisoning. If a baby is hyper-sensitive to mercury, or reacts abnormally to mercury, and is exposed to mercury, then Pink Disease is the result. The most commonly used product containing mercury WAS teething powder, but other products frequently used on babies also contained mercury.

The symptoms included weepy red rash, peeling skin, lethargy, anaemia, sensitivity to light, respiratory distress and general ill health. About 25% of babies with Pink Disease died.

In 1947, it was discovered that mercury was the cause of Pink Disease and mercury was removed from all teething powders by the late 1950's. Only one in 500 babies given teething powders was diagnosed as having Pink Disease. After mercury was removed from teething powder, Pink Disease became rare.

A previous information gathering exercise by the Pink Disease Support Group has revealed a much higher than average incidence of Multiple Sclerosis, Lupus, non-specific auto-immune disorders, Bronchiecstasis, Solar Urticaria, chemical sensitivities, allergies, and has suggested a proneness to psychiatric disorders.

If you have any of the mentioned diseases, or have suffered from mercury poisoning, I would be grateful if you would complete the Survey. Your name and address are OPTIONAL.

This is a rather long survey. PLEASE answer every question. There will be NO annoying prompt stopping you from sending just because you left out some answers.

Your name and address and any identifying information you give the Pink Disease Support Group WILL NOT be released to anyone else.

Thank you.

Diane Farnsworth,
Pink Disease Support Group,
Statistician and Researcher.

Q.  PRELIMINARY QUESTIONS

Q1. Do you have Multiple Sclerosis? yes no

Q2. Do you have Lupus? yes no

Q3. Do you have Bronchiectasis? yes no

Q4. Do you have Solar Urticaria? yes no

Q5. Do you have Rheumatoid Arthritis? yes no unknown

Q6. Have you had mercury poisoning? yes no unknown

Q7. Do you have a serious psychiatric disorder? yes no unknown If yes, what type?

Q8. If you answered Y to any of the above, age of onset: years

Q9. If you answered Y to any of the above, CAUSE, if known.

Q10. Have you had any poisoning episode (food/chemical etc yes no unknown

Q11. Are you ultra-sensitive to any heavy metals yes no unknown

Q12. Did you have Pink Disease? yes no unknown

A.  SYMPTOMS SUFFERED AS A BABY/TODDLER

A1 Red rash yes no unknown

A2 Skin peeled off in layers. yes no unknown

A3 Clammy hands and feet yes no unknown

A4 Very physically fragile? yes no unknown

A5 Constant crying until completely exhausted? yes no unknown

A6 Bashed head or body against cot or other objects? yes no unknown

A7 Spent time in hospital yes no unknown

(if yes, how long days)

A8 Did your doctor decline to put you in hospital
because you were too sick & nothing could be done to help? yes no unknown

A9 Had to be kept in dark room because of photophobia (acute sensitivity to light). yes no unknown

A10 Putrid body odour or motions? yes no unknown

A11 Lost appetite yes no unknown

A12 Lost weight yes no unknown

A13 Lost muscle tone (e.g. like a rag doll) yes no unknown

A14 Sucked or chewed fingers/hands? yes no unknown

A15 Any type of anaemia? If yes, what type? yes no unknown If yes, what type?

A16 Who gave you the above details?

QUESTIONS A17 TO A21 ARE TO BE ANSWERED BY PEOPLE WHO HAD PINK DISEASE.

A17 If you were already walking when you got Pink disease did you have to learn to walk again? yes no unknown not applicable

A18 If not walking when you got Pink disease, how old were you when you first walked? months

A19 Age of onset of Pink disease months

A20 Cause of the disease, if known

A21 What treatment, if any, were you given?

B.  EYES

Have you had or do you have any of the following?

B1 Spots or flashes of light (falling like rain before eyes.) never rarely sometimes often always unknown

B2 Tunnel vision never rarely sometimes often always unknown

B3 Night blindness never rarely sometimes often always unknown

B4 Sensitivity to sunlight (need sunglasses even in winter) never rarely sometimes often always unknown

B5 Sockets of eyes ache never rarely sometimes often always unknown

B6 Retinitis (inflammation of the retina) never rarely sometimes often always unknown

B7 Keratitis (inflammation of the cornea) never rarely sometimes often always unknown

B8 Dimness of vision in one or both eyes never rarely sometimes often always unknown

B9 Short/long sighted. If yes, which? other short long

B10 How old were you when you first got glasses? years

B11 Retinitus Pigmentosa yes no unknown

B12 Corneal dystrophy/degeneration yes no unknown

B13 Been prescribed or used Vitamin A for improved vision yes no

B14 Been prescribed or used any other vitamins or minerals (e.g. Vitamin B2, Zinc) for improved vision. yes no If yes, what?

C.  MOUTH AND THROAT

Have you had or have any of the following?

C1 Thyroid treatment never rarely sometimes often always unknown

C2 Have trouble swallowing never rarely sometimes often always unknown

C3 Feel as if something is caught in your throat never rarely sometimes often always unknown

C4 Unexplained coughing fits never rarely sometimes often always unknown

C5 Persistent cough never rarely sometimes often always unknown

C6 Pain when yawning never rarely sometimes often always unknown

C7 Clenching or grinding of teeth in sleep. never rarely sometimes often always

C8 Metallic taste in mouth never rarely sometimes often always

C9 Swelling of parotid glands (cheek to ear) never rarely sometimes often always unknown

C10 Swelling of Submaxillary glands (under jaw) never rarely sometimes often always unknown

C11 Treatment for Temporomandibular joint never rarely sometimes often always unknown

C12 Excessive cavities in teeth yes no

C13 Early loss of teeth yes no If yes, at what age?

C14 Do you have dentures? yes no If yes, at what age?

C15 Any amalgam fillings in teeth? yes no If yes, how many?

C16(a) Have you had all your amalgams removed? yes no

C16(b) If yes, by a dentist specialising in amalgam removal? yes no

C16(c) Was the removal followed by a mercury detoxification program? yes no

C16(d)Has your health deteriorated since the amalgam removal? yes no
If yes, how much?

C16(e) Has your health improved since the amalgam removal? yes no
If yes, how much?

D.  BLOOD

Have you had or do you have any of the following?

D1 Iron deficiency anaemia never rarely sometimes often always unknown

D2 Vitamin B12 (pernicious) anaemia never rarely sometimes often always unknown

D3 Any other type of anaemia? never rarely sometimes often always unknown If so, type

D4 Frequent bouts of anaemia for no known reason never rarely sometimes often always unknown

D5 Excess iron in your blood never rarely sometimes often always unknown

D6 Unexplained low haemoglobin blood count never rarely sometimes often always unknown

D7 Any unexplained, unusual results from blood tests never rarely sometimes often always unknown

E.  MUSCLES & BONES

Have you had or do you have any of the following?

E1 Poly-myalgia (painful muscles & ligaments, especially in your feet , elbows and knees.) never rarely sometimes often always unknown

E2 Arthritis like symptoms never rarely sometimes often always unknown

E3 Poor muscle tone in general or loss of muscle tone never rarely sometimes often always unknown

E4 Pectoral or pelvic girdle (hips 'click') never rarely sometimes often always unknown

E5 Spurs on heels never rarely sometimes often always unknown

E6 Costal chondritis (painful cartilage connecting ribs & sternum) never rarely sometimes often always unknown

E7 Loss of strength in arms (can't hold things above head) never rarely sometimes often always unknown

E8 Osteoporosis (brittleness and softness of bones) yes no unknown

F.  CO-ORDINATION

Have you had or do you have any of the following?

F1 Do you drift when walking (into walls, etc)? never rarely sometimes often always unknown

F2 Do you stumble when walking? never rarely sometimes often always unknown

F3 Do you have poor hand/eye co-ordination - eg. go to open fridge and miss handle completely; type or write words in a jumbled fashion? never rarely sometimes often always unknown

F4 Do you have a poor sense of distance? never rarely sometimes often always unknown

F5 Do you have a poor sense of direction? never rarely sometimes often always unknown

F6 Are you clumsier than average? never rarely sometimes often always unknown

F7 Do you jumble your words and/or have difficulty communicating what you are thinking in words or writing? never rarely sometimes often always unknown

G.  ALLERGIES & CHEMICAL SENSITIVIEIES.

Are you allergic/sensitive to any of the following?

G1 Foods. yes no unknown If yes, please list.

G2 Medicines yes no unknown If yes, please list.

G3 Cosmetics yes no unknown don't use them If yes, please list.

G4 Chemicals yes no unknown If yes, please list.

G5 Food additives? yes no unknown If yes, please list.

G6 Metals? yes no unknown If yes, please list.

G7 Do you suffer from hayfever? never rarely sometimes often always unknown

H.  GENERAL.

Have you had or do you have any of the following?

H1 Headaches never rarely sometimes often always unknown

H2 Migraines never rarely sometimes often always unknown If yes, how severe?

H3 Unexplained tiredness never rarely sometimes often always unknown

H4 Do you feel hungover in the mornings for NO REASON? never rarely sometimes often always unknown

H5 Chronic tiredness never rarely sometimes often always unknown

H6 Do you prefer salty foods to sweet foods? never rarely sometimes often always unknown

H7 Do you prefer sweet foods to salty foods? never rarely sometimes often always unknown

H8 Do you feel the cold more than average? never rarely sometimes often always unknown

H9 Do you feel the heat more than average? never rarely sometimes often always unknown

H10 Do you sweat excessively? never rarely sometimes often always unknown

H11 Do you sweat excessively on your face? never rarely sometimes often always unknown

H12 Numbness in any part of the body never rarely sometimes often always unknown

H13 Ear problems never rarely sometimes often always unknown

H14 Excessive pain when you bump your legs/arms never rarely sometimes often always unknown

H15 Excessive body odour never rarely sometimes often always unknown

H16 Poor nutritional absorption never rarely sometimes often always unknown

H17 Do you have digestive problems? never rarely sometimes often always unknown

H18 Do you have constipation? never rarely sometimes often always unknown

H19 Do you have diarrhea? never rarely sometimes often always unknown

H20 Trouble losing weight never rarely sometimes often always unknown

H21 Trouble gaining weight never rarely sometimes often always unknown

H22 Do you have a poor immune system? never rarely sometimes often always unknown

H23 Have you suffered from any form of cancer. yes no unknown If so what type?

H24 Are you taking any medication? yes no unknown If so what type?

H25 Kidney problems. yes no unknown If yes, type?

H26 Liver problems. yes no unknown If yes, type?

H27 Bladder Problems. yes no unknown If yes, type?

H28 Have you been DIAGNOSED as having Chronic Fatigue Syndrome or Myalgic Encepthalomyelitis. yes no unknown
If yes, CFS or ME?

H29 Have you been DIAGNOSED as having multiple sclerosis? yes no

H30 Have you been DIAGNOSED as having any auto-immune disorder? yes no

H31 Have you been DIAGNOSED as having Lupus? yes no

H32 Does your doctor suspect you have an auto-immune disease? yes no

H33 Do you suffer from loss of hearing? yes no

H34 Do you have mis-shapen fingers or nails? yes no

H35 Do you have problems with your hands/or feet? yes no If yes, give details.

H36 Do you have Rheumatoid Arthritis? yes no unknown

H37 Do you have Raynaud's Syndrome? yes no unknown

H38 Do you have Scleroderma? yes no unknown

H39 Do you suffer from Restless Legs Syndrome? yes no unknown

H40 Have you had exposure to mercury from any source
apart from dental amalgams? (eg. medicines, work, contact
lens solutions) yes no unknown

H41 Do you have Ross River Fever? yes no

J.  SKIN.

Have you had or do you have any of the following?

J1 Skin problems. never rarely sometimes often always unknown If yes, what sort?

J2 Icthyotic skin (dry scaly skin) never rarely sometimes often always unknown

J3 Psoriasis (red patches covered by grey scaly skin) never rarely sometimes often always unknown

J4 Is your skin prone to rashes? never rarely sometimes often always unknown

J5 Do you sunburn easily? never rarely sometimes often always unknown

J6 Do you get a rash from sunlight exposure? never rarely sometimes often always unknown

J7 Do you get red spots from sunlight exposure? never rarely sometimes often always unknown

J8 Are you prone to dermatitis? never rarely sometimes often always unknown

J9 Is your skin dry (for a person your age)? yes no unknown

J10 Was your skin dry as a child? yes no unknown

J11 Did you have wrinkly hands as a child? yes no unknown

J12 Are you unusually fair skinned (not inherited)? yes no unknown

K.  HEART and LUNGS.

Have you had or do you have any of the following?

K1 Asthma never rarely sometimes often always unknown If you do, age of onset? years

K2 Breathlessness from even minor exertion never rarely sometimes often always unknown

K3 Bronchitis never rarely sometimes often always unknown

K4 Chest/heart pains (angina attacks) never rarely sometimes often always unknown

K5 Tachycardia (racing heart) never rarely sometimes often always unknown

K6 Poor blood circulation (pins and needles) never rarely sometimes often always unknown

K7 Bronchiectasis (dilation of the small bronchial tubes) yes no unknown

K8 Any other lung disorder? yes no unknown If yes, type?

K9 Mitral valve problems yes no unknown

K10 Heart murmur yes no unknown

K11 Heart problems yes no unknown

K12 Do you suffer from unexplained dizzy spells? never rarely sometimes often always unknown

K13 Do you have high/low/normal blood pressure? high normal low unknown

L.  STRESS LEVEL, EMOTIONAL WELLBEING & PERSONALITY.

Have you had or do you have any of the following?

L1 Nightmares never rarely sometimes often always unknown

L2 Insomnia never rarely sometimes often always unknown

L3 Do you need excess sleep never rarely sometimes often always unknown How much sleep do you need per day?

L4 Depression never rarely sometimes often always unknown If yes, how severe?

L5 Suicidal thoughts never rarely sometimes often always unknown

L6 Feelings of helplessness never rarely sometimes often always unknown

L7 Do you suffer from forgetfulness? never rarely sometimes often always unknown

L8 Do you lack self confidence? never rarely sometimes often always unknown

L9 Are you a nervous person? never rarely sometimes often always unknown

L10 Do you lack attention in conversation? never rarely sometimes often always unknown

L11 Are you shy? never rarely sometimes often always unknown

L12 Are you sensitive to noise? never rarely sometimes often always unknown

L13 Are you a "loner" or do others think you are a "loner"? never rarely sometimes often always unknown

L14 Are you moody or do others think you are a moody person? never rarely sometimes often always unknown

L15 What is your ability to cope with stress? poor average good

L16 How much stress do you suffer? not much average lots

L17 Is your emotional level? poor average high

L18 General physical health level on a scale of 1 to 10 (10 best)

L19 Have you been DIAGNOSED as having clinical depression? yes no

L20 Have you been DIAGNOSED as having bipolar disorder (manic depression)? yes no

L21 Have you been DIAGNOSED as having schizophrenia? yes no

L22 Have you been DIAGNOSED as having a schizoid personality? yes no

L23 Have you been DIAGNOSED as having any mental illness? yes no

L24 If you have answered YES to any one of questions L18 to L22, is the illness inherited? yes no unknown not applicable

M.  CHILDHOOD ILLNESSES.

Have you had any of the following?

M1 Did you have Whooping Cough? yes no unknown

M2 Did you have German Measles? yes no unknown

M3 Did you have the Measles? yes no unknown

M4 Did you have Glandular Fever? yes no unknown

M5 Did you have Scarlet Fever? yes no unknown

N.  FOR WOMEN ONLY

N1 Have you suffered from fertility problems? yes no unknown

N2 Have you had any miscarriages? yes no

N3 Have you had any still-births? yes no

N4 Have you had an hysterectomy? yes no If yes, why & what age?

N5 Do you or did you have excessively painful and incapacitating period pain? never rarely sometimes often always

N6 Did you suffer any other gynaecological problems? yes no

N7 Is your hair unusually thin? yes no

N8 Do you suffer from unexplained hair loss? yes no

N9 Do you need to wear a wig? yes no

N10 Have you given birth to a handicapped child? yes no
If yes, what kind of handicap?

N11 Do you have or did you had severe premenstrual tension? never rarely sometimes often always

P.  FOR MEN ONLY

P1 Have you had fertility problems? yes no unknown

P2 Have you suffered from Young's syndrome? yes no unknown

P3 Have you had any other men's problems? yes no

P4 Do you have unexplained hair loss (not inherited)? yes no

Your comments

You may have other problems not mentioned above, or you may be suffering very severely, or maybe some of the problems you have an explanation. (e.g. your kidney problems are inherited, or your health problems are caused by old age, or yo ur hearing loss is due to industrial deafness.) Please give us any information you think may be useful. Thank you.