Prosopagnosia Research Centers at Harvard University and University College London

CONTACT INFORMATION
First Name*
Last Name*
Title
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Gender*	Female Male
Birth Date*
	Do you believe you have problems with face recognition?
*	Yes No
	Do you believe that your family members have problems with face recognition?
	Yes No
REFERRAL INFORMATION
	Did someone who may be prosopagnosic direct you to this site?
	Yes No
	If so, please provide the following information:
Referral Name
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You can contact the Prosopagnosia Research Center using the form below.
1.	Do you believe that you have face recognition difficulties?
	Yes No
2.	Please describe some incidents in which you have been unable to recognize others.

3.	How do you typically recognize others?

4.	When did you realize that you might have face recognition problems?

5.	Have you ever experienced head trauma, amblyopia (lazy eye), cataracts, severe untreated myopia, or other serious visual problems?

6.	Do you believe that you have any other face processing difficulties such as recognition of facial expressions of emotion, eye gaze direction determination, or the extraction of sex, age, attractiveness, etc from the face?

7.	Do you believe that you have trouble recognizing non-facial objects such as cars, animals or places?

8.	Do you believe that your navigational abilities are poor compared to others?

9.	Do you think that any of your family members share your difficulties or have other neurological problems? If so, please provide their relationship to you and their difficulties.

10.	Do you think that you have any other neurological problems? If yes, please describe them.

11.	Is there anything else that you think is relevant to your condition?

12.	Please check this box if we may contact you.