Is this story about:
Your diagnosis
Another person’s diagnosis (i.e. your child or parent)
Your details
Title
Please select...
Mr
Ms
Miss
Mrs
Mx
Dr
Prof
Rev
First name
Last name
Email address
Phone number
Date of birth
Gender
Male
Female
Other
What's your ethnicity?
Please select...
White – English/Welsh/Scottish/ Northern Irish/British
White - Irish
White - Any other white background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any Other Mixed Background
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Any Other Asian Background
Chinese
Black - African
Black - Caribbean
Any Other Black Background
Other Ethnic Group
Prefer Not to Say
Postcode
Address line 1
Address line 2
Town / City
County
How old is the person with a brain tumour?
Adult (over 30)
Teenage/Young Adult (16-30)
Child (under 16)
What's your relationship to person with a brain tumour?
I'm their
Please select...
Parent
Partner
Child
Sibling
Step-parent
Step-child
Grandparent
Relative
Friend
Colleague
Pupil
Professional
Legal guardian
Other
What's the status of person with a brain tumour
Living with
Lost
Your diagnosis
When were you diagnosed?
Within the last two weeks
Within the last four weeks
More than four weeks ago
Date of diagnosis (if known)
How old were you when you were diagnosed?
How many visits to a GP did you make before you were diagnosed?
Were you misdiagnosed?
Yes
No
Original diagnosis
Who referred you for a scan?
Please select...
Specialist
GP
Optician
A&E
Out of Hours Services
Private Healthcare
What type of brain tumour do you have? (if known)
Please select...
Acoustic neuroma (also known as vestibular schwannoma)
Anaplastic astrocytoma
Astrocytoma
AT/RT (atypical teratoid/rhabdoid tumour)
Brain stem glioma
Choroid plexus tumours
CNS lymphoma
Craniopharyngioma
Diffuse astrocytoma
DIPG (also known as diffuse midline glioma)
Embryonal tumours (including PNETs)
Ependymoma
Familial tumour syndromes (including NF1/2, Von Hippel and schwannomatosis)
Fibrillary astrocytoma
Ganglioglioma
Germ cell tumour
Glioblastoma (GBM)
Haemangioblastoma
Medulloblastoma
Meningioma
Metastatic brain tumour
Mixed glioma
Oligodendroglioma
Optic nerve glioma
Pilocytic astrocytoma
Pineal region tumour (including pineoblastoma)
Pituitary tumour
Schwannomas
Spinal cord tumour
Unspecified glioma
Other
Unknown
Other tumour type
What's the grade of your tumour?
Low grade (1-2)
High grade (3-4)
Please tell us your story here
Or upload a short video of your story
Please upload a photo of yourself
Where can we share your story? (This may be online or offline)
Please select...
Anywhere
Press
Radio
TV
Charity Publications
To select multiple, hold the Ctrl key and select.
Their details
Title
Please select...
Mr
Ms
Miss
Mrs
Mx
Dr
Prof
Rev
First name
Last name
Date of birth
Gender
Male
Female
Other
What's their ethnicity?
Please select...
White – English/Welsh/Scottish/ Northern Irish/British
White - Irish
White - Any other white background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any Other Mixed Background
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Any Other Asian Background
Chinese
Black - African
Black - Caribbean
Any Other Black Background
Other Ethnic Group
Prefer Not to Say
When were they diagnosed?
Within the last two weeks
Within the last four weeks
More than four weeks ago
Date of diagnosis (if known)
How old were they when they were diagnosed?
How many visits to a GP did they make before they were diagnosed?
Were they misdiagnosed?
Yes
No
Original diagnosis
Who referred them for a scan?
Please select...
Specialist
GP
Optician
A&E
Out of Hours Services
Private Healthcare
Tumour type (if known)
Please select...
Acoustic neuroma (also known as vestibular schwannoma)
Anaplastic astrocytoma
Astrocytoma
AT/RT (atypical teratoid/rhabdoid tumour)
Brain stem glioma
Choroid plexus tumours
CNS lymphoma
Craniopharyngioma
Diffuse astrocytoma
DIPG (also known as diffuse midline glioma)
Embryonal tumours (including PNETs)
Ependymoma
Familial tumour syndromes (including NF1/2, Von Hippel and schwannomatosis)
Fibrillary astrocytoma
Ganglioglioma
Germ cell tumour
Glioblastoma (GBM)
Haemangioblastoma
Medulloblastoma
Meningioma
Metastatic brain tumour
Mixed glioma
Oligodendroglioma
Optic nerve glioma
Pilocytic astrocytoma
Pineal region tumour (including pineoblastoma)
Pituitary tumour
Schwannomas
Spinal cord tumour
Unspecified glioma
Other
Unknown
Other tumour type
Grade of tumour
Low grade (1-2)
High grade (3-4)
Please tell us their story here
Or upload a short video of their story
Please upload a photo of them
Where can we share their story? (This may be online or offline)
Please select...
Anywhere
Press
Radio
TV
Charity Publications
To select multiple, hold the Ctrl key and select.
Keeping in touch
We'd also love to keep you up-to-date on how we are making a difference with our eNewsletter, this will include information about research, support services and how you can get involved, for example by fundraising, campaigning or volunteering.
Can we keep you up to date via email?
Yes
No
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or calling 01252 237792.
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