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  • Member

Contact Information

Country
State / Province*
Address
City
Email*
Confirm Email*
Phone
Date of Birth (dd/mm/yyyy)

It is important to us to be able to engage with you and keep you up to date with the latest news about encephalitis and our work.  This might include fundraising and research or other aspects of our work that help us meet our primary aim of improving the quality of all lives affected by this often-devastating condition. Please tell us how you prefer to hear from us and the different ways that we can keep in touch with you.

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  • Post
  • Email
  • Telephone
  • Does not consent (details removed)
Are you interested in finding out more about volunteering
  • Yes
About you*
  • Bereaved
  • Family Member
  • Friend
  • Parent
  • Person Affected
  • Supporter

Encephalitis Details

Please complete the details below if applicable:

Name of Person Affected
Date of Birth of Person Affected (dd/mm/yyyy)
Age at Diagnosis
Age at Second Diagnosis (Please leave blank if not applicable)
Deceased Date (Please leave blank if not applicable)
Other Type (Not Listed Above)
Physical Problems
  • Weight Gain / Overeating
  • Weight Loss / Loss of Appetite
  • Endocrine
  • Hemiplegia
  • Quadriplegia
  • Paraplegia
  • Visual
  • Audiotory
  • Sensitive Hearing
  • Touch
  • Smell
  • Taste
  • Body Temperature Control
  • Left Side Weakness
  • Right Side Weakness
  • Balance / Coordination
  • Ataxia
  • Difficulty with purposeful movement (Dyspraxia)
  • Difficulty with pronunciation (Dysarthia)
  • Difficulty with writing (Dysgraphia)
  • Difficulty with swallowing (Dysphagia)
  • Bowel Incontinence
  • Bladder Incontinence
Cognitive Problems
  • Short Term Memory
  • Long Term Memory
  • Specific e.g. for names
  • Word Finding
  • Understanding
  • Dyslexia
  • Dysexecutive Functions
  • Attention
  • Concentration
  • Problem-Solving
  • Planning
  • Information Processing
  • Perception
  • Recognition
  • Judgement and Lack of Insight
  • Learning Difficulties
  • Development Delay
  • Slowed Responses
  • Unaware of Risk
Behavioural Problems
  • Personality Change
  • Motivation
  • Perseveration
  • Irritable
  • Aggression
  • Socialisation
  • Disinhibition
  • Obsessions
  • Frustrations
  • Anger
  • Confabulation
  • Self Neglect
Emotional Problems
  • Mood Swings
  • Anxiety
  • Depression
  • Loss of Confidence
  • Psychiatric
  • Phobias
  • Paranoia
  • Delusions
Other Problems
  • Epilepsy (Controlled)
  • Epilepsy (Tonic-Clonic)
  • Epilepsy (Partial)
  • Epilepsy (Absences)
  • Epilepsy(Nocturnal)
  • Headaches
  • Fatigue
  • Sleep Problems
  • Lowered Immune System
Problems Note
Additional Comments