Registration

First Name

Family ID

Username *

User Password *

Last Name

Is this the primary contact?

User Email *

Confirm Password *

Alternate Contact Full Name

Alternate Contact Phone

address

City

State

zip

Home Phone

Cell Phone

Other Phone

Birthday Select your birthday

Race of primary

If other specify:

Gender?

Which hand were you born to write with?

Do you have any relatives with Dystonia?

If

Do you have Dystonia symptoms?

What year did your Dystonia symptoms begin? (yyyy)

At what age were you when the Dystonia symptoms began?

Have you been tested for the DYT1 gene or any other genetic form of dystonia?

If so what genetic forms were you tested for?

What was the result of your genetic test?

Where were you diagnosed? (city / clinic or hospital / lab)

What Form of Dystonia do you have?

What Type of Dystonia do you have?

Location of your Dystonia symptoms now?

What other treatments have you tried?

Have you had Deep Brain Stimulation Surgery (DBS)?

If

Where was DBS performed?

Do we have permission o contact you for clinical trials?