Childhood Stroke
Participant Details
First Name
Last Name
Personal Email
Phone
I am a:
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Childhood survivor of stroke
Parent
Carer
Family member
Friend
Allied health professional
Medical or nursing professional
Aboriginal Health Worker
Researcher
Teacher
Other
The stroke occurred:
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Less than 1 year ago
1-2 years ago
2-5 years ago
5-9 years ago
10+ years ago
Not applicable
Age at stroke:
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Before birth or within 1 month of birth
1-12 months
1-2 years
3-5 years
6-10 years
11-17 years
Not applicable
State
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VIC
NSW
ACT
QLD
WA
SA
TAS
NT
Other/International
How did you find out about us?
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Stroke Foundation
Social Media
Childhood Stroke (OFSJ/LSW)
Word of Mouth
Doctors /Health Professional
Other
Your age group:
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Under 18 years old
18-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65 years or older
I consent to being contacted via email to receive regular updates and invitations to take part in projects
I am under 18 years old
You are under 18, we need to make sure your parent/guardian agrees to you receiving updates from us
Parent/guardian's Name
Parent/guardian's phone number
Parent/guardian's email
I have discussed receiving updates from Stroke Foundation about Childhood Stroke work with my parent/guardian
Hidden Use Only
True
Bypass Validation Rules (Patient Contact)
Bypass Validation Rules (GP Contact)
Bypass Validation Rules (Carer/Next of Kin Contact)
Form Auto-Assign (Case)
Health Record (Contact)
Business Hours (Case)
Record Type ID (Case)
Child Stroke Queue ID
Case Type (Case)
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Childhood Stroke Project
Case Origin (Case)
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Web
Subject (Case)
Body
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