ST/Dystonia » About Us » Quick Survey

About Us Quick Survey

Will You Give Us 5 Minutes of Your Time?

Fill out this confidential survey to help us build the prototype of what Mr./Mrs./Ms. ST'r would be like. Why is this so important? So that we can tell the media about us; so that we can tell the researchers and doctors about us as well as the legal world and the general public. THIS MAY SPEED UP GETTING A CURE! All information is and will remain confidential. We do not need your name!

Email Address (optional)
Age
Gender
How many years have you had ST?
Do you work?	Yes No
Had to quit work?	Yes No
Because of ST?	Yes No
What was your income when working?
Has ST changed your lifestyle?	Yes No
Stay at home more?	Yes No
Problems with family not understanding?	Yes No
Attend church?	Yes No
Attend movies?	Yes No
Attend special events?	Yes No
Shopping is all but impossible?	Difficult No problem
Embarrassed?	Yes No
Had to give up hobbies?	Yes No
If divorced, was it because of ST?	Yes No
Is driving impossible?	Yes No
Do you tire easily?	Yes No
Has depression become a problem?	Yes No
Do you have panic attacks?	Yes No
Are you a sensitive type person?	Yes No
Do you have pain? If so, on a scale of 1 - 10 (10 being the worst), what would you rate yours at?

ST/Dystonia (Spasmodic Torticollis)

Providing HOPE for your future.

About Us Quick Survey

Will You Give Us 5 Minutes of Your Time?