Name: (optional)
E-mail: (optional)
What month were you born?
January
February
March
April
May
June
July
August
September
October
November
December
In what year were you born?
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
In what state were you born?
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
When pregnant, did your mother drink well water or bottled water?
Well water
Bottled water
Did your mother take pre-natal vitamins throughout her pregnancy with you?
Yes
No
Did your mother have any liver issues pre-pregnancy, during pregnancy or post-pregnancy with you?
Yes
No
Please describe:
Were you a full-term baby?
Yes
No
Were you 'jaundice' at birth?
Yes
No
Were your stools immediately pale after birth?
Yes
No
At what age were you diagnosed with BA?
At what hospital were you diagnosed?
At what age did you have the kasai?
Were you put on steroids post kasai?
Yes
No
What was your bilirubin levels for the 3 months post kasai? (approx)?
Did you have colangitis?
Yes
No
Did you have a transplant?
Yes
No
If yes, what age did you go on the transplant list?
What age did you receive your transplant?
From whom was your transplant?
Living family member
Living non-family donor
Deceased donor
Was your transplant successful?
Yes
No
Do you have any questions you would like to see added to our survey?
Do you have a theory about what may cause Biliary Atresia?
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