Devic's and NMO Worldwide Support 

Gayle's Place: People supporting people, around the world  

Survey

 

 

Because Devic's / NMO is a rare condition, researchers need to find out as much as possible about those people who are affected by it. This kind of data will help people with Devic's / NMO get faster diagnosis and better treatments.

We would be very grateful if you could take the time to fill in the survey below. The information will go directly to the group's medical adviser. We promise not to pass on any data that could identify you personally to anyone without your consent. We may use the information you give us in various different ways, but cases will be grouped together or "anonymised".

Thanks for your help!

Gayle

Fragebogen in Deutsch!

Devic's / NMO Survey

I am a:	Person with Devic's/NMO Parent/Guardian of a child with Devic's/NMO Carer for an adult with Devic's/NMO Other Please select
	other (please state)
Personal details
First name
Surname
Gender	Male Female
Date of Birth	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
House no / name & street
Area
Town / City
County / State
Country
Postcode / Zip code
Contact telephone numbers:	Day
(Please include area	Evening
and national codes)	Mobile
E-mail address	This is required
If you do not have Devic's / NMO yourself, and are not a carer / parent / guardian of someone with the condition, that is all the information we need. Please go to the bottom of the form and click the button to submit. Thank you. If you are a carer / parent / guardian, please complete the rest of the form as it relates to the person with Devic's / NMO. Thank you. Please let us know if any of your personal details change.
Ethnic origin: White British Chinese Please tick the box White Irish Other Asian background that most closely White other Mixed - White / Black Caribbean describes your Black - Caribbean Mixed - White / Black African ethnic origin Black - African Mixed - White and Asian   Black - other Other mixed   Asian - Indian Other ethnic group   Asian - Pakistani Not known   Asian - Bangladeshi Prefer not to say
Doctors' names GP Name Consultant Neurologist Name Other consultant (related to your Devic's / NMO) Name
Diagnosis of your neurological condition   Have you had a definite diagnosis of Devic's / NMO? Yes No Have you had a probable diagnosis of Devic's / NMO? Yes No Have you had a possible diagnosis of Devic's / NMO? Yes No
When was the above diagnosis given?
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Who gave the diagnosis?
Doctor's name Hospital
Previous diagnoses or suspected diagnoses
Relating specifically to your Devic's / NMO symptoms, have you ever been diagnosed with or suspected of having any other neurological condition? (Please tick all that apply)
Multiple sclerosis
Optic neuritis
Transverse Myelitis
Acute Disseminating Encephalopathy Myelitis (ADEM)
Other neurological condition
If "other", please state:
Thank you!
Human Check- please enter the name of the sort of animal in the picture. (Click on it to enlarge)
Please now click on the button below to submit the survey.