Name: Email address: Telephone number: Address: City: State: ZipCode: Country: Best way to be contacted: If by phone, what is the best time to reach you? How long of a time commitment are you interested in making (weeks, months)? How many hours a week/month could you commit? Are you the: person diagnosed with angiomas parent of a child diagnosed with angiomas spouse or caregiver of a person diagnosed with angiomas
The following questions pertain to the person diagnosed with angiomas.
When were you/they diagnosed with an angioma/angiomas? Do you/they have a solitary angioma or multiple angiomas? a solitary angioma multiple angiomas If a solitary angioma, where is it located? If multiple angiomas, do you know where your/their symptomatic angiomas are located? Have you/they had surgery or are you/they contemplating surgery? If not, have you/they been advised that surgery is not the best option for your/their angioma/angiomas or that it is currently inaccessible? What symptoms have you/they experienced as a result of your/their angioma/angiomas? Have they resolved or are they ongoing? Do you/they have seizures or pain? Have you been relatively stable physically and emotionally for the last six months? That does not necessarily mean that you are holding down the same job you had previously, or that you don’t have some deficits from your cavernous angioma. But it does mean that you are relatively comfortable with your new or changed life. Yes No What is your/their birth date? Are you/they married? Yes No Do you/they have children and if so, how many? If you/they have children, how old are they? Do you consider yourself spiritual? Yes No
