Calling everyone with a Sturge-Weber Diagnosis

Be part of the Group!

The Sturge-Weber Foundation wants to know how many people are diagnosed with Sturge-Weber Syndrome in the World! Please fill out our survey and let's update our numbers today. Thank you for time.

*This is for internal use at the SWF

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* 1. Are you the patient or caregiver?

Patient

Caregiver, Please answer the survey as if you were the patient.

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* 2. Do you have a diagnosis of Sturge Weber Syndrome?

Yes

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* 3. Do you have a port-wine birthmark?

Yes

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* 4. Do you have a diagnosis of glaucoma?

Yes

Other (please specify)

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* 5. Have you experienced seizures?

Yes

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* 6. Have you experienced migraines or headaches?

Yes

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* 7. Do you want to be a member of the Birthday Club?

Yes

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* 8. Please update information for the patient so we can update our records.

Name

Date of Birth

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 9. What is the best way to communicate with you?

By Mail

Social Media ie Facebook, Twitter, LinkedIn, Instagram, TikTok

Other (please specify email address or handle)

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* 10. What topics do you want to hear more about?

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* 11. Demographics: What is your gender?

Male

Female

Other

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* 12. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)