HYPERICIN SURVEY

If you have used hypericin (St. John's wort extracts), or know anyone who has, whether or not any results were seen, you can help with this survey. All identifying information will be kept confidential. Please complete this questionnaire even if you have already told us about your use of the treatment.

Use the back of this sheet, or use additional paper, whenever necessary. Please print or type.

A. Initials of person using hypericin: (Optional--you may omit this information. If you provide it, we will keep it confidential. We are requesting it to help us avoid counting the same person more than once.)

First initial _____

Last initial _____

State of residence (or country if not U.S.) _____


B. Hypericin preparation used (circle one or more):

Yerba Prima tablets

Psychotonin tincture

Hyperforat tincture

Jarrow Formulas tincture

Herb Pharm tincture

Other (please specify) _______________


C. What daily dose was used? (Specify tablets, drops, or other.
Explain on back if necessary.) _____


D. How long was it used, in weeks? _____ (Explain on back if necessary.)


E. Benefits which you believe might have been due to hypericin: (Use back of sheet if needed.)


F. Side effects or harm which you believe might have been due to hypericin: (Use back of sheet if needed.)


G. Symptoms or conditions which failed to improve while you used hypericin: (Use back of sheet if needed.)


H. P24 antigen levels, if available:


Before starting hypericin (include date of blood drawing) _____

After using hypericin (include number of weeks of treatment use at time of blood drawing) _____


I. T-helper cell counts, if available:

Before starting hypericin (include date of blood drawing) _____

After using hypericin (include number of weeks of treatment use at time of blood drawing) _____


J. Other treatments:

AZT (circle one: yes / no). Dose: _____

Other antivirals (please specify, and give dose): _______________

Other treatments we should know about (please list):


K. Optional: If we can contact you in case we have any further questions, please give us your name and phone number:


L. In your own words, what do you think of hypericin? Also, use this space to tell us anything else we should know.


STATEMENT OF PURPOSE

AIDS TREATMENT NEWS reports on experimental and complementary treatments, especially those available now. It collects information from medical journals, and from interviews with scientists physicians, and other health practitioners, and persons with AIDS or ARC.

Long-term survivors have usually tried many different treatments, and found combinations which work for them. AIDS TREATMENT NEWS does not recommend particular therapies, but seeks to increase the options available.

We also examine the ethical and public-policy issues around AIDS treatment research.