AHS Guestbook

Name:

Address:

City:

State:

Zip:

Home Phone: ( Area Code & number)

Business Phone: ( Area Code & number)

Email Address:

How did you hear about us? (Examples: Referred by doctor, relative, newspaper/magazine article, etc.) Please include name and date of newspaper/magazine, etc.

Your involvment: Patient Physician Family Member Friend Scientist Med. Student Nurse Other

Please tell us your story:

% of Saturation at Diagnosis?: (Also known as transferrin saturation percentage/TS)

Serum Ferritin at Diagnosis?:

Date of Original Diagnosis?:

Liver Biopsy? Yes No

Did you have the HFE Hemochromatosis Genetic Test? (DNA Test)? Yes No

If yes, please provide the following information

1. Genetic Lab which performed your test?

Please choose one of the following results:

Homozygote for Cys282Tyr Mutation (double gene mutation) Also known as 845A.
Heterozygote for Cys282Tyr Mutation (single gene mutation) Also known as 845A.
Homozygote for His63Asp Mutation (double gene mutation) Also known as 187G.
Heterozygote for His63Asp Mutation (single gene mutation) Also known as 187G.
Compound Heterozygote ( one gene mutation of the Cys282Try and His63Asp)
Homozygote for C65D gene mutation
Heterozygote for C65D gene mutation
None

Current % Of Saturation?

Current Serum Ferritin Level?

Additional Comments: (symptoms, abnormal liver enzymes, etc.)