Tell us about you. Name * First Name Last Name Email * Phone * (###) ### #### Preferred Date MM DD YYYY Why are you interested in a brain scan and consultation? The question below will help us assess your risk of stroke. The answers to all of the questions below are optional. What is your age? What is your sex? Male Female What is your ethnicity? White Asian Black Other Do you smoke tobacco? No Ex-smoker Yes - less than 10 per day Yes - between 10 and 20 per day Yes - more than 20 per day Do you have diabetes? Yes No Does anyone in your immediate family have angina or suffered a heart attack? Yes No Don't know Do you have any other health conditions? Tell us anything else you would like us to know.
