New Patient Registration Survey
Name:
Name:
Field Is Required
First
Field Is Required
Last
Suffix
Suffix
Sr.
Jr.
II
III
IV
V
Required
Date of Birth:
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Date of Birth:
Month
Jan
Feb
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Apr
May
Jun
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Day
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Year
1900
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1911
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2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
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2024
2025
2026
2027
2028
2029
Gender:
Gender:
Male
Female
Required
Address:
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Street 1:
Street 2:
City/Town:
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City/Town:
State / Province:
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State / Province:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
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LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
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OR
PA
RI
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SD
TN
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WI
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AS
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MH
MP
PR
PW
VI
AA
AE
AP
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
None
Required
ZIP / Postal Code:
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ZIP / Postal Code:
Country:
Country:
United States
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivarian Republic of Venezuela
Bonaire, Sint Eustatios and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic People's Republic of Korea
The Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Federated States of Micronesia
Fiji
Finland
The Former Yugoslav Republic of Macedonia
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iraq
Ireland
Islamic Republic of Iran
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Plurinational State of Bolivia
Poland
Portugal
Puerto Rico
Qatar
Republic of Korea
Republic of Moldova
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
S. Georgia & S. Sandwich Isls.
Sierra Leone
Singapore
Sint Maarten (Dutch)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United Republic of Tanzania
Uruguay
USA Minor Outlying Islands
Uzbekistan
Vanuatu
Viet Nam
Virgin Islands (British)
Virgin Islands (USA)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Required
Email:
Email:
Phone Number:
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.
Field Is Required
By providing your phone number you are opting into text messages from ALS United Greater Chicago.
Please select response
Yes
No
What is your primary language?
What is your secondary language (if applicable)?
How did you hear about us?
PCP
Neurologist
Mayo Clinic
MDA
Media Ad
Website
Other
Field Is Required
Marital Status:
Married
Single
Separated
Divorced
Widowed
Other
If married, spouse's name:
Do you have children and/or grandchildren between the ages of 0 - 26?
Please select response
Yes
No
Are your children and/or grandchildren between the ages of 0 - 8?
Please select response
Yes
No
Are you children and/or grandchildren between the ages of 9 - 18?
Please select response
Yes
No
Are you children and/or grandchildren between the ages of 19 - 26?
Please select response
Yes
No
Primary caregiver's name and relationship:
(Maximum response 255 chars, approx. 5 rows of text)
Caregiver's email address:
Field Is Required
Caregiver's phone number:
Are you presently employed?
Please select response
Yes
No
If yes, name of employer:
What is your primary source of health insurance?
Medicare
Medicaid
Private
Are you a veteran?
Please select response
Yes
No
Field Is Required
Date of ALS diagnosis:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Field Is Required
Is there any other person(s) in your family with ALS?
Please select response
Yes
No
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)
Current Symptoms (please mark all that apply)
Weakness in hands
Weakness in feet
Weakness in neck
Difficulty speaking
Difficulty walking
Difficulty with saliva
Difficulty breathing
Difficulty swallowing
Weight loss
Muscle cramps
Fasciculations
Assistive Devices (please mark all devices that you are currently using):
Tub seat
Bedside commode
Raised toilet seat
Wheelchair
Cane
Ramp
Lift chair
Hoyer lift
Hospital bed
Walker
Communication device
Please select the racial category with which you most closely identify (select one):
African-American
Asian
Hispanic
Native American
Caucasian
Other
If "Other", please elaborate:
Have you been informed about the National ALS Registry?
Please select response
Yes
No
Are you eligible for the National ALS Registry?
Please select response
Yes
No
Are you registered with the National ALS Registry? If you are not registered please visit www.cdc.gov/als to register.
Please select response
Yes
No
Are you currently enrolled in any clinical trials?
Please select response
Yes
No
If not, are you interested in enrolling?
Please select response
Yes
No
Additional information:
Field Is Required
Have you (or a caregiver on the patient's behalf) already spoken to a member of our staff?
No
Yes, with Joumana (Vice President of Care Services)
Yes, with Peggy (Director of Care Services)
Yes, with Brianna (Care Services Coordinator)
Yes, with Kellie (Care Services Coordinator)
Yes, with Gema (Care Services Coordinator)
Yes, with Snovea (Care Services Coordinator)
Yes, with another Chapter staff member
Field Is Required
Are you currently receiving services from any ALS-affiliated organizations? If yes, please elaborate below:
Please select response
Yes
No
ALS-affiliated organizations:
Spam Control Text:
Please leave this field empty