CADASIL Trust Registration Form

Thank you for registering with the CADASIL Research and Support Trust.

By registering you are agreeing to allow us to send you regular updates on our work and what we are doing.

All information that you give will not be passed on to any other organisation or person, and will be used for statistical analysis only. The information relating to your doctor will allow us to contact him/her independantly, and offer him/her our support and keep him informed of any advances, seminars etc relating to CADASIL to enable him/her to provide you a more informed medical service.

For more information, please read our privacy policy.

Your Height If Known

Your Weight If Known

Are You A CADASIL Patient?

Are You A CADASIL Patient Carer?

Other? Please Specify

Your Doctors Address

Your Doctors Contact Number

Your Doctors Email Address If known

Other Type of Doctor (Please Specify)

Rating Of Doctors Knowledge of CADASIL

If Other Method Please Specify

Were You Diagnosed With A Disorder
Other Than Cadasil e.g. MS?
(Please Specify)

Have you been diagnosed with any of the following?
(tick all that apply)

Mr Jack Shields has advocated the use of L-Arginine as a treatment for CADASIL -
Have You Tried Jacks Treatment?

If Yes How would You Rate The Benefits?

Would You Be Willing To Take Part In Other Questionnaires?

Would You Like to Be Kept Informed Of Our Work?

All fields marked with a* are required:
Your Name*
Your Address
Your Country*
Your Email Address*
Your Date of Birth
Your Height If Known
Your Weight If Known
Are You A CADASIL Patient?
Are You A CADASIL Patient Carer?
Other? Please Specify
Your Doctors Name
Your Doctors Address
Your Doctors Contact Number
Your Doctors Email Address If known
Type Of Doctor	General Practitioner Neurologist Psychiatrist Other
Other Type of Doctor (Please Specify)
Rating Of Doctors Knowledge of CADASIL	Excellent Very Good Satisfactory Poor Very Poor
Date Of Diagnosis
Method of Diagnosis	Skin Biopsy Gene Screening Family History Brain Imaging Other
If Other Method Please Specify
Were You Diagnosed With A Disorder Other Than Cadasil e.g. MS? (Please Specify)
Have you been diagnosed with any of the following? (tick all that apply)	High Blood Pressure Cardiovascular Disease Diabetes
Are You A Smoker?	Yes No
Mr Jack Shields has advocated the use of L-Arginine as a treatment for CADASIL - Have You Tried Jacks Treatment?	Yes No
If Yes How would You Rate The Benefits?	Excellent Very Good Satisfactory Poor Very Poor
Would You Be Willing To Take Part In Other Questionnaires?	Yes No
Would You Like to Be Kept Informed Of Our Work?	Yes No