We would love for you to become a monthly donor and help us achieve our research funding goals. You can sign-up as a monthly donor here:







send the information below to This e-mail address is being protected from spambots. You need JavaScript enabled to view it , and you will receive an email back with information regarding the study! If you have visual snow syndrome, please

Please provide the following information within your email:





Name



Address



Date of Birth (Day/Month/Year)



Telephone number





1) Please make a brief statement that you are willing to be contacted for research. This is a European data protection issue.



example:

"Yes, please keep my contact details and you may contact me for research purposes."





2) Brief description of all symptoms you relate to visual snow syndrome.





3) Date or age when your symptoms started.





4) Visual snow: what type (chose one):



- black and white (i.e. only black dots on white background, white dots on black background)



- clear (i.e. color of the background)



- flashing (i.e. always white, brighter than background)



- colored



- all of these





5) Other symptoms (please only answer yes or no)



- After images



- Trailing of images in the vision



- Blue field entoptic phenomenon (i.e. white squiggly lines moving pulsating on the blue sky)



- Floaters in vision



- Colored clouds or waves with eyes closed



- Flashes of light



- Impaired night vision



- Sensitive to light



- Tinnitus





6) Have you ever been diagnosed with migraine or have you had a headache of moderate or severe intensity in the past? ( Please answer yes or no)





7) Have you ever taken any illicit drugs in the past?







