Exit this survey

Parent leaflet input survey

Thank you for taking the time to complete this survey. Your opinions are very much appreciated and will help us create a better and more relevant leaflet. Thank you.

Question Title

* 1. Please complete your details if you are happy for us to contact you at the end of this survey:

Name:

City/Town:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

Question Title

* 2. Child details

Name:

Gender:

Age:

Age diagnosed:

Question Title

* 3. How long did it take to diagnose ataxia?

Question Title

* 4. What type of ataxia does your child have?

Question Title

* 5. Where did you go for initial information?