STARS US

THIS INFORMATION WILL REMAIN CONFIDENTIAL AND PROTECTED BY THE ORGANIZATION

1. Title*
2. First Name*
3. Last Name*
4. Email Address*
5. Telephone Number*
6. Cell Number
7. Address*
8. City*
9. State*
10. Zip Code*

If you are a Medical Professional, please complete the following:

1. Speciality
2. Address
3. City
4. State
5. Zip Code
6. Place of Work

If you are not a Medical Professional, please complete the following:

1. Relationship to Sufferer
2. I am The Patient The Parent/Caregiver Spouse Friend Grandparent Other Relative Medical Professional
3. Your Date of Birth 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 January February March April May June July August September October November December 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
4. Sufferers Date of Birth 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 January February March April May June July August September October November December 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
5. Diagnosis made Yes / No
6. If Yes - please provide a brief description
7. Who made it? Neurologist Cardiologist Pediatrician Pediatric Cardiologist Pediatric Neurologist Emergency Room Doctor Primary Care Physician Geriatrician GP
8. Please provide the name and address for your doctor so we can send them information about STARS:
9. Doctor's Name
10. Address
11. City
12. State
13. Zip Code
14. Telephone
15. Current Treatment
16. No Treatment
17. Medication Name
18. Pacemaker
19. Other
20. Tests carried out - please check as many that apply
    None
    Tilt Table
    Ocula
    ECG
    Blood
    Iron Level
    ILR
    EEG
    Heart Monitor
    Pacemaker
    Other
21. Other Comments

Optional Information

1. Household Income 10,000-50,000 50,000-100,000 100,000-250,000 250,000-500,000 500,000-above
2. Ethnic background for funding purposes only Caucasian African American Asian Hispanic Other (please specify)
3. Other