We can't cure Meniere's Disease but we can help you live with it. Regular text size Larger text size Print this page Bookmark, email or share

MA Membership Survey

If you are joining MA - or you are already a member ...

... please take a few minutes to complete the following online member survey. Any information you can provide will help us to improve and better target our services to members. We will not pass on your personal information to other parties without your consent. All information is optional.

Title:
First name:
Surname:
Phone:
Email:
Year of birth:
Current occupation:
Previous occupation:
How long have you been a member of Meniere's Australia?
I have just applied for membership:
Less than 1 year:
1-5 years:
Over 5 years:
I joined/want to join Meniere's Australia because -
I have Meniere's disease:
A family member or friend has Meniere's:
I have a professional interest in Meniere's:
Fill out the following sections only if you have Meniere's disease. If you have only filled in the above section, please remember to click the 'Send' button at the bottom of this form.
What symptoms do you experience?
Vertigo (dizziness):
Hearing loss:
Tinnitus (abnormal noise in the ear):
Sensitivity to sound:
Anxiety/emotional issues:
Other symptoms:
(please specify)
I am under the care of -
GP (local doctor):
Ear Nose & Throat (ENT) Specialist:
Neurologist:
Other care:
(please specify)
I have had surgery for Meniere's -
Yes:
No:
(MathGuard)
Please solve our security math question by adding the two numbers together
and typing your answer in the text box:

N           8UI      
L T    N    1 8   U8T
B6Q   WR9   AB9      
  E    J      T   TAH
  P         YW9

What's this?

 

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About Meniere's Australia
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Last Updated January 2011