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CADASIL Registry
Please complete this secure form if you have been diagnosed with CADASIL diagnosed by blood test or skin biopsy
* Indicates required question
Name
*
Your answer
Email
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Country
*
Your answer
Year of Diagnosis
*
Your answer
Age of Diagnosis
*
Your answer
Ethnicity/Race
Your answer
Blood Type if Known
Your answer
Were you ever diagnosed with MS
No
Yes
Clear selection
Asymptomatic
No
Yes
Clear selection
Balance/Gait
No
Yes
Clear selection
Bladder
No
Yes
Clear selection
Dementia
No
Yes
Clear selection
Depression
No
Yes
Clear selection
Fatigue
No
Yes
Clear selection
Headache
No
Yes
Clear selection
Hearing
No
Yes
Clear selection
Itching
No
Yes
Clear selection
Memory
No
Yes
Clear selection
Migraines
No
Yes
Clear selection
Migraines with Aura
No
Yes
Clear selection
Mood
No
Yes
Clear selection
Numbness
No
Yes
Clear selection
Speech
No
Yes
Clear selection
Sensation
No
Yes
Clear selection
Weakness
No
Yes
Clear selection
Other symptoms not listed
Your answer
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