Name:

Email address:

Telephone number:


Address:


City:

State:

ZipCode:

Country:


Best way to be contacted:
Email
Telephone
Initial phone call; email follow-up
No preference
If by phone, what is the best time to reach you?

The following questions will help us try to match you with a support person who has had a similar experience to you, and is possibly at a similar life stage. If you don’t have very much information about your situation yet, that is fine, just answer whatever you can.

1. When were you diagnosed with a cavernous angioma/angiomas?


2. Do you have:
a solitary angioma
multiple angiomas

If a solitary angioma, where is it located?


If multiple angiomas, do you know where your symptomatic angiomas are located?


3. Have you had surgery or are you contemplating surgery? If not, have you been advised that surgery is not the best option for your angioma/angiomas or that it is currently inaccessible?


4. What symptoms have you experienced as a result of your angioma/angiomas? Have your symptoms resolved or are some ongoing?


5. Do you have seizures?
Yes
No

6. Personal Information:

What is your birth date?


Are you married?
Yes
No

Do you have children and if so, how many, ages?
Yes
No


Some people rely heavily on their spiritual beliefs during difficult times. If this is true for you, would you prefer a peer partner with a similar religious background? If so, what is your religious background?


Are there any other factors you would like us to consider when matching you with a peer partner?


I understand that Angioma Alliance peer support is not a substitute for obtaining competent medical advice. Furthermore, I understand that although Angioma Alliance has tried to establish many safeguards, Angioma Alliance cannot be held liable for any injury that occurs as a result of the peer partner program.

Thanks for sharing your information. We will do our best to match you with a Peer Partner that can be helpful in supporting you through this difficult time.