Beat SCAD - SCAD patient information
Beat SCAD would like to gather as much information as possible about SCAD patients for support and statistical purposes.

You are free to give us as much or as little information as you like.

If your circumstances change and you'd like to update or change your information, please email us (contactus@beatscad.org.uk).

You can withdraw consent at any time by using this form or contacting us (contactus@beatscad.org.uk) to let us know which information you do not want us to keep any more.

Your personal information will be kept private and held securely. We will never share your details with anyone else without your consent.

Thank you

The Beat SCAD Trustees

Email address *
Please give us a few details about yourself
Title *
First name *
Your answer
Surname *
Your answer
Address
Your answer
Home phone number
Your answer
Mobile phone number
Your answer
Are you a SCAD patient? (If you are not a SCAD patient but would like us to keep in touch with you, please complete our Keep in Touch form (www.beatscad.org.uk/keep-in-touch) *
Required
Please tell us about your SCAD(s)
How many SCAD events have you had *
What date did you have your first SCAD? Please include day, month and year.
Your answer
How old were you when you had your first SCAD?
Your answer
What were the circumstances of your first SCAD?
Your answer
What date did you have your second SCAD? Please include day, month and year.
Your answer
How old were you when you had your second SCAD?
Your answer
What were the circumstances of your second SCAD?
Your answer
What date did you have your third SCAD? Please include day, month and year.
Your answer
How old were you when you had your third SCAD?
Your answer
What were the circumstances of your third SCAD?
Your answer
If you have had more than three SCADs, please add details here.
Your answer
Which hospital(s) were you treated at?
Your answer
Have any of your family members also had one or more SCADs?
Have you signed up to take part in the UK research project in Leicester? (scad.lcbru.le.ac.uk)
Did you attend a Research Day at Glenfield Hospital, Leicester between 28.5.2015 and 4.7.2017?
If Yes, what date did you attend?
MM
/
DD
/
YYYY
Have you requested a referral to a SCAD specialist in Leicester or London?
If Yes, has this referral been successful?
Have you been screened for Fibromuscular Dysplasia (FMD)?
Have you had a diagnosis of FMD?
Are you a member of the SCAD UK & Ireland SCAD Survivors closed Facebook group?
If Yes, please let us know if you are happy for any of your details below to be shared with the members of the closed Facebook group.
Would you be willing for Beat SCAD to contact you about telling your story on our website
Data protection
Data protection legislation requires you to give us explicit consent that we can keep ‘special category data’, which includes information on health conditions.

The information we keep is listed above. We will use it to support SCAD patients and for statistical purposes.

Your personal information will be kept private and held securely and will never be shared with third parties.

You can change your mind at any time by filling in this form again or emailing us at contactus@beatscad.org.uk.

*
Required
We respect your privacy – for full details of our Website privacy policy see www.beatscad.org.uk/privacy-policy and our Data processing policy see www.beatscad.org.uk/what-we-do-with-your-personal-data *
Required
Thank you from the Beat SCAD Team
A copy of your responses will be emailed to the address you provided.
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