Registration for In-Clinic Diagnostic Session

First name:

Last name:

Email:

Your country and city of residence:

Contact phone number:

Date of birth (dd/mm/yyyy):

Date of the facial palsy onset (dd/mm/yyyy):

What caused your facial palsy?
Unknown reason (Bell's palsy)Herpes virus (Ramsay Hunt)Last weeks of pregnancyCongenitalOperation (surgery)TraumaOther. Please specify:

Affected side:
RightLeftBoth

What treatments/medication did you take during the acute period?

Which therapy was prescribed and taken?

When did the first signs of recovery appear?

When did the improvements slow down or eventually stop?

What treatments did you take during the last 3 months and what were the results:

What complaints about your face and facial movements do you have at the moment (as detailed as possible):

Comments or questions:

How did you hear about us?
GoogleInstagramYouTubeFacebook GroupsFacebookFriends/FamilyMy doctorOther:

I have read and accept the Terms & Conditions

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