Enquiry form test EN - NeuroAiD™

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Is NeuroAiD for you?

Tell us about the patient and we'll get in touch

Choose condition*

Stroke

Alzheimer's disease

Traumatic brain injury

Other

Patient's information

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Who is the patient?*

Patient's Age*

Condition details (Traumatic brain injury)

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Year of diagnosis / Injury*

Cause of injury*

If others, please specify:*

Who managed the follow-up after the injury?*

If others, please specify:*

Current level of independence*

Main symtoms or difficulties (TBI)*

(select all that apply)

Physical symptoms (e.g. headache, dizziness, photosensitivity, fatigue)

Cognitive symptoms (e.g. memory, attention, thinking)

Behavioural symptoms (e.g. mood, anxiety, irritability)

Others

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Condition details (Other conditions)

Year of diagnosis*

Who made the diagnosis?*

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Contact information

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last name*

Last name*

Name

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Email*

Country*

Question or comment

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Enquiry - EN (Test)

Is NeuroAiD for you?

Patient's information

Condition details (stroke)

Condition details (Alzheimer's disease)

Condition details (Traumatic brain injury)

Condition details (Other conditions)

Contact information