Survey - New Patient Registration Survey - The ALS Association Greater Chicago Chapter

Name:

Field Is Required First

Field Is Required Last

Suffix

Field Is Required Date of Birth:

Gender:

Field Is Required Street 1:

Street 2:

Field Is Required City/Town:

Field Is Required State / Province:

Field Is Required ZIP / Postal Code:

Country:

Email:

Field Is Required Phone Number:

If you respond and have not already registered, you will receive periodic updates and communications from ALS United Greater Chicago.

What is your primary language?

What is your secondary language (if applicable)?

If married, spouse's name:

Do you have children or grandchildren? If so, what are their ages?

Primary caregiver's name and relationship: (Maximum response 255 chars, approx. 5 rows of text)

Caregiver's email address:

Are you presently employed?

If yes, name of employer:

What is your primary source of health insurance?

Are you a veteran?

Field Is Required Date of ALS diagnosis:

Field Is Required Is there any other person(s) in your family with ALS?

If yes, what is their relationship to you?

Field Is Required Neurologist's name, address, and phone: (Maximum response 255 chars, approx. 5 rows of text)

Primary physician's name, address, and phone: (Maximum response 255 chars, approx. 5 rows of text)

Please select the racial category with which you most closely identify (select one):

If "Other", please elaborate:

Have you been informed about the National ALS Registry?

Are you eligible for the National ALS Registry?

Are you registered with the National ALS Registry? If you are not registered please visit www.cdc.gov/als to register.

Are you currently enrolled in any clinical trials?

If not, are you interested in enrolling?

Additional information:

Field Is Required Have you (or a caregiver on the patient's behalf) already spoken to a member of our staff?

Field Is Required Are you currently receiving services from any ALS-affiliated organizations? If yes, please elaborate below:

ALS-affiliated organizations:

Spam Control Text: Please leave this field empty