CHD2 - CCC

This is a pre-registration page so we can contact you for an interview. We may also send a secondary survey in due course if necessary. This information will be held securely and will be deleted once the project has been completed.

You do not have to complete every question but the more information provided, the more helpful it will be for us. This survery will take approximately 15 minutes to complete.

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* 1. Patient's full name

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* 2. Patient date of birth

Date - US format (MM/DD/YY)

Date

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* 3. Patient Sex

Male

Female

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* 4. Patient current weight - please include the unit (pounds or kilograms)

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* 5. Is your child under a neurology or epilepsy team currently?

Yes

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* 6. If you answered yes to the question above, please provide the folowing details:

Clinician Full Name

Hospital or clinic name and location

Clinician Email Address

Clinician Phone Number

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* 7. Please provide your full name so we can get in touch.

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* 8. Enter your personal email address.

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* 9. Enter your phone number with the country code.

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* 10. Do you have any videos of seizures that you would be happy to share?

Yes