Sign up now to connect with an Activa DBS Ambassador.
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* How would you like to be contacted? Email Phone
* Would you prefer to be contacted by a ... Male ambassador Female ambassador No Preference
* What year were you diagnosed with Parkinson's disease? 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 or Earlier
* What is your age? 18 - 24 25 - 34 35 - 49 50 - 64 65 - 75 75 +
* What is the best time of the day to call? Morning After Noon Evening
Who is the physician treating your Parkinson's disease symptoms?
* Do you experience troubling "off" periods (periods when medication is not helping enough and you are experiencing symptoms)? Yes No
* Do you experience troubling dyskinesias (involuntary excessive movements)? Yes No
* How many doses of dopaminergic drugs (Levodopa, Sinemet, Stalevo, Parcopa) do you take in a typical day? 0 1 2 3 4 5 6 7 8 9 10 More than 10
* Do you currently have an Activa DBS system? Yes No
* Do you experience any of the following troubling side effects from your medications, despite having tried several drug combinations? (sleepiness, nausea, hallucinations, confusion/other thinking problems, light-headedness upon standing, behavioral/personality changes) Yes No
What topics would you like to discuss with the Activa DBS Ambassador? Maximum characters: 300 Characters remaining:
*I have read the Important Safety Information regarding Activa DBS.
Please Note: This service cannot answer any questions about medical issues or Parkinson's disease. For medical questions, please see your doctor.
By completing and submitting this form you are granting Medtronic permission to add your contact information to its database for Parkinson's disease and consent to receiving future emails, mailings, and materials relating to Medtronic's products and services. Medtronic respects the confidentiality of personal information. We assure you that we will not share your personal information, except as otherwise noted in our privacy policy located at www.medtronic.com/statements/privacy.html. To remove your name from Medtronic's Discover Activa DBS mailing list at any time, you may email support@discoveractivadbs.com or send a request in writing to: Medtronic Discover Activa DBS, Medtronic, Inc., 710 Medtronic Parkway - LN275, Minneapolis, MN 55432
