Telling your story could help others

Name:

*

Address:

*

Phone:

*

Fax:

Email:

*

1. How were you affected by meningitis? Please select: Patient Parent Family Member Friend *

2. Patient's Name:

*

3. Patient's Gender. Please select:

Male Female *

4. Patient's age when contracted meningitis: *
Year patient contracted meningitis: *

5. Type of meningitis (if known):

*

7. Your story - Please tell us what happened including the signs and symptoms, your experiences with medical personnel, treatment and how long the illness lasted etc:
*

8. Outcome and after effects - Please tell us about any after effects caused as a result of meningitis (Eg. Any disabilities or recurring illnesses) and how you are today:
*

9. What assistance or information do you feel would have helped you at the time? (Eg. Being more aware of the symptoms, having a care plan for recovery, support groups etc.)
*

QUICK QUESTIONS

May we contact you for possible media stories (using your story)?    Yes    No

Would you be interested in meeting others who have experienced meningitis?    Yes    No

Would you be interested in attending family support meetings?    Yes    No

Are you interested in being kept up-to-date on the activities of The Meningitis Centre?    Yes    No

Are you interested in assisting The Meningitis Centre?    Yes    No

Are you interested in becoming a peer supporter / contact for others who have experienced meningitis and scepticaemia?    Yes    No

SUBMIT YOUR STORY

Before submitting your story please read the privacy statement .

I have read and understand the privacy policy and quidelines and accept the organisation's privacy statement'. Can you please change the text to - I have read, understand and accept the organisation's privacy statement