Become the Face of Peripheral Neuropathy Home Support Become the Face of Peripheral Neuropathy [printfriendly] Share your story and inspire others! Submit Your Patient Story SalutationMr.Mrs.Ms.Dr.First Name * Required Last Name * Required Email * Required Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Share your name? * RequiredUse my first name onlyI would prefer to remain anonymousPlease let us know how or if you would like your name to appear if we publish your story.Share your location? * RequiredYes, it is ok to share my City/StateList my State onlyList my City onlyNo, please do not list my City/StateBy default, we will share the City/State that you provide to us if we use your story. If you would prefer to have your location remain anonymous, please select "No" above.Phone Number We will never share your phone number. It is NOT required to list it here. We will only use this phone number if we have a question about your "Share Your Story: submission to FPN.Relationship to patientI am the patientSpouseOther family memberFriendOtherGive your story a title Your Story: Help us define the Face of Peripheral Neuropathy! * RequiredHow can you inspire others to live their best lives possible with this challenging and very painful medical condition? Please think about this question as you start to share your story which may include synopsis from your time living with PN; a single or series of unique PN experiences; a poem or even a letter to your doctor or loved one. Use your imagination and get creative. Remember to include relevant facts. Please include some or all of these topics (and others) as you share your story: What is your connection to peripheral neuropathy? How did you develop PN? When and how were you diagnosed with peripheral neuropathy? Who diagnosed your PN(what type of specialist diagnosed you)? What type of PN do you have? What body parts are most affected? How have you been managing your PN and what type of specialists help you manage your PN? What’s the number one thing that helps you manage PN the best? What do you wish people knew about PN? How do you describe PN to people who have never heard of it? What inspires you to face PN head-on and how do you do it? How has PN prompted you to make positive lifestyle change(s)? What advice would you give others going through the same journey? What is your motto to live by? Upload a Photo of the PatientAccepted file types: jpg, pdf, Max. file size: 10 MB.Maximum file size - 10 mega bytes. Upload a photo of the authorAccepted file types: jpg, pdf, Max. file size: 10 MB.Maximum file size - 10 mega bytes. Upload other photos or files Drop files here or Select files Accepted file types: jpg, pdf, Max. file size: 10 MB, Max. files: 3. Maximum file size - 10 mega bytes. Permission to Publish * Required Yes By submitting your story/photo and clicking the checkbox above, you grant the Foundation for Peripheral Neuropathy permission to use your story, photo, first name, and city/state/country (if permission is granted herein) without any compensation to you for as long as the Foundation wishes to do so. The Foundation for Peripheral Neuropathy may use your story in whole or in part in print or promotional materials, on its website, its emails, its social media, or its communications. We will never publicly use your last name, email, or phone number. The Foundation for Peripheral Neuropathy has the right to edit or modify your submission without further approval from you. You release the Foundation of Peripheral Neuropathy and its employees, directors and agents from any direct, consequential or incidental damages or liabilities regarding use of the Submission and your name/location as designated herein. You confirm that you are 18 years or older.
