Your Name

Email Address

Telephone Number

Mobile Telephone Number

Address (inc Postcode)

It is helpful to STARS if you can provide us with the following information.

If you are Medical Professional, what is your place of work

If you are not a Medical Professional:

Relationship to Sufferer:
I am the Patient I am the Parent Spouse Friend Grandparent Other Relative Medical Professional

Sufferers D.O.B

Diagnosis:
Syncope Vaso Vagal Syncope (VVS) Reflex Anoxic Seizures (RAS) Collapse Fainting Blackouts Neurocardiogenic Syncope (NCS) Neurally Mediated Syncope (NMS) Neurocardiogenic Syncope (NCS) Transient Loss of Conciousness (T-Loc) Searching for diagnosis Breath-holding Panic Attacks Blackouts Temper Tantrums Epilepsy Allergy Pseudosyncope Depression Other

If a diagnosis has been made, who made it?

Neurologist

Paediatric Cardiologist

Paediatric Neurologist

Cardiologist

Paediatrician

GP or Primary Care Physician

Emergency Department Doctor

Geriatrician

Please provide the name and address for your doctor/consultant so we can send them information about STARS:

Current Treatment:

No Treatment

Beta Blockers

Atropine

Midodrine

Pacemaker

Anti-Convulsant

Anti-Depressant

Epilem

Tegratol

Other Therapy

Other drugs (please state)

If other, please state:

Tests carried out: please check as many that apply.
None
Tilt Table
Ocular Compression
ECG
EEG
Blood Pressure
Iron Level
ILR
Heart Monitor
Pacemaker

Other

If you are a UK taxpayer and would like to Gift Aid your subscription/donations to STARS so we can collect an additional 28p per pound from the taxman, please tick the box. (I confirm that I am a UK taxpayer and I wish STARS (Syncope trust And Reflex anoxic Seizures) to claim Gift Aid on all donations I make to the charity from 6 April 2007 until further notice from me.)

Any further comments?

Thank you for subscribing to STARS.

When you hit the 'send' button you will be able to click on a link to pay by paypal (min £15/$25/25 Euros). If you prefer to pay offline, send cheques /postal orders payable to STARS, to STARS, PO Box 175, Stratford Upon Avon, Warwickshire, CV37 8YD.

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