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Peer Support Volunteer Questionnaire

Contact Information



















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



 


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