Research / Support Questionnaire

Research / Support Questionnaire

This form is for individuals who have had family members affected by aneurysms (including self). If there is no family history of aneurysms, please do not complete this form.
Go to our Guest Registry at this time.

Be a star

Please play a part in creating a pathway into a brighter future by completing this registry and questionnaire. The gathering of mass amounts of accurate and timely statistics is vital for researchers to find similarities in those affected.

FIELDS MARKED WITH * ARE REQUIRED! Your Name:* Address:* City:* State/Province:* Postal Code:* Country:* Daytime Phone:* Home Phone: Best Time to Contact: E-Mail Address:*

It is also imperative that we join together, both to build awareness about aneurysms and their devastation and then to promote change. Please prayerfully consider checking the box below to allow Aneurysm Outreach Inc. to use your name in all petitions including those directed to governmental agencies to generously support grant funding in all aneurysm arenas.

  Please check
   I grant Aneurysm Outreach Inc. permission to use my
        name in petitions to accomplish their mission
        statement of mobilizing people and resources
                 to eradicate aneurysms.

Below is AOI's research and support questionnaire. Your time and patience in accurately completing all categories that pertain to you are greatly appreciated. There is a section at the bottom for your questions and comments. Again, thank you for choosing to assist in this work.


    Family History of Aneurysms (Include yourself)


            Number of Family Members affected.

            Of family members affected by aneurysms

            Indicate Type:
            (A = aortic, B = brain, O = other),
            Relationship to you and Age of ONSET
            (age when person became aware of aneurysm).

            Examples:For Person Box
            A - self - 50
            A - father - 55
            B - paternal uncle - 58
            O - maternal aunt - 66  etc.

    Person 1
    

    Person 1 - is/was smoker
     Yes  No  Unknown

    Person 1 - has/had hypertension (high blood pressure).
     Yes  No  Unknown

    Person 1 - has/had peripheral vascular disease
    (Example:hardening of the arteries, claudication, stroke).
     Yes  No  Unknown


    Person 2
    

    Person 2 - is/was smoker
     Yes  No  Unknown

    Person 2 - has/had hypertension (high blood pressure).
     Yes  No  Unknown

    Person 2 - has/had peripheral vascular disease
    (Example:hardening of the arteries, claudication, stroke).
     Yes  No  Unknown


    Person 3
    

    Person 3 - is/was smoker
     Yes  No  Unknown

    Person 3 - has/had hypertension (high blood pressure).
     Yes  No  Unknown

    Person 3 - has/had peripheral vascular disease
    (Example:hardening of the arteries, claudication, stroke).
     Yes  No  Unknown


    Person 4
    

    Person 4 - is/was smoker
     Yes  No  Unknown

    Person 4 - has/had hypertension (high blood pressure).
     Yes  No  Unknown

    Person 4 - has/had peripheral vascular disease
    (Example:hardening of the arteries, claudication, stroke).
     Yes  No  Unknown


    Person 5
    

    Person 5 - is/was smoker
     Yes  No  Unknown

    Person 5 - has/had hypertension (high blood pressure).
     Yes  No  Unknown

    Person 5 - has/had peripheral vascular disease
    (Example:hardening of the arteries, claudication, stroke).
     Yes  No  Unknown


    Person 6
    

    Person 6 - is/was smoker
     Yes  No  Unknown

    Person 6 - has/had hypertension (high blood pressure).
     Yes  No  Unknown

    Person 6 - has/had peripheral vascular disease
    (Example:hardening of the arteries, claudication, stroke).
     Yes  No  Unknown


  I am willing to participate in a more extensive
    study with researchers and/or submit blood samples.



 Physician Support

         I am a physician who wishes to assist AOI in
         accomplishing its mission statement of eradicating
         aneurysms.  Please contact me.



 


 Join "Friends of AOI" by:

           Giving my tax-deductible donation of
                $

                or tax-deductible gift of
                

            Volunteering my services
                Area of expertise, desired area of service,
                and/or network connections
                

            Committing to pray for AOI regularly.


 How did you find us:

***IMPORTANT NOTICE***

This site was created to raise public awareness about the threat of aneurysms, especially the fact that certain families have a predisposition toward their occurrence, to stimulate and fund genetic research through advocacy and tax-deductible donations and to coordinate a support network for those affected or at risk and their families. We are NOT able to give medical treatment advice. These questions should be directed to your physician.

Please type any comments or questions here: