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Patients Needed for Visual Snow Study in London PDF Print E-mail

 

Please provide the following information within your email:

Name

Address

Date of Birth (Day/Month/Year)

Telephone number


1) Please make a brief statement that you are willing to be contacted for research. This is a European data protection issue. 

example:       
"Yes, please keep my contact details and you may contact me for research purposes."


2) Brief description of all symptoms you relate to visual snow syndrome. 
   

3) Date or age when your symptoms started.
 

4) Visual snow: what type (chose one):

-          black and white (i.e. only black dots on white background, white dots on black background)

-          clear (i.e. color of the background)

-          flashing (i.e. always white, brighter than background)

-          colored

-          all of these


5) Other symptoms (please only answer yes or no)


-          After images

-          Trailing of images in the vision

-          Blue field entoptic phenomenon (i.e. white squiggly lines moving pulsating on the blue sky)

-          Floaters in vision

-          Colored clouds or waves with eyes closed

-          Flashes of light

-          Impaired night vision

-          Sensitive to  light

-          Tinnitus

6) Have you ever been diagnosed with migraine or have you had a headache of moderate or severe intensity in the past? ( Please answer yes or no)


    7) Have you ever taken any illicit drugs in the past?