Fibrosing Mediastinitis

"A little information can go along way"

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The information obtained here will be used to maintain a database of patients with Fibrosing Mediastinitis.  Since the number of patients is limited, gathering this information is critical in understanding the disease and compiling demographic and treatment information.  If you have any questions or concerns please contact Tricia at tlewy1@yahoo.com.

Please provide the following contact information:

First Name
Last Name
City
State/Province
Zip/Postal Code
E-mail

Please provide the following information:

Date of Birth
Sex Male Female

Please identify your type of FM:

Histoplasmosis FM
Idiopathic FM

Please enter the date of diagnosis:

Please describe your history, treatment and symptoms:

What are your current medications?

Where is your treatment center?

What follow up do you do for the disease?

Is it okay to contact you via email?

Tricia Edgell is not responsible or liable to the user for damages of any kind arising out of information provided in this form.  Data or information provided to Tricia Edgell shall be used and relied upon only at the users sole risk, and the user agrees to indemnify and hold harmless Tricia Edgell from any liability arising out of the data or information provided.  By completing this form, the user agrees to have information made public for research and educational purposes.
Tricia Edgell
Copyright © 2006. All rights reserved.
Revised: 10/11/06