Survey - New Patient Registration Survey - ALS United Greater Chicago

New Patient Registration Survey

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.

Field Is Required By providing your phone number you are opting into text messages 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 and/or grandchildren between the ages of 0 - 26?

Are your children and/or grandchildren between the ages of 0 - 8?

Are you children and/or grandchildren between the ages of 9 - 18?

Are you children and/or grandchildren between the ages of 19 - 26?

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?

If yes, name of employer:

What is your primary source of health insurance?

Medicare
Medicaid
Private

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?

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 Ramos (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:

ALS-affiliated organizations:

Spam Control Text: Please leave this field empty