ALS Worldwide

Patient Online Profile

* First Name

* Last Name

* Email

* Address

* City

* State

* Postal Code

* Country

Mobile Phone

* Phone

* Birthdate

* Occupation/Job Description

Skype ID

Marital Status

Spouse Name

Children's Names and Ages

Siblings' Names and Ages

Emergency Contact Person

Relationship to Patient

Emergency Contact Email

Emergency Contact Phone Number

Participant Form Consent: It is my understanding that I am offering voluntarily the medical information collected via this form with the clear understanding that the information is NOT protected in any way by the Health Insurance Portability and Accountability Act (HIPAA) However, ALS Worldwide does follow HIPAA guidelines and will not share information you provide without your permission.

* Participant Form Consent

* Date of Diagnosis

Name of Your Neurologist and Clinic

* Initial Symptoms

* Current Symptoms

Rate of Progression

Mobility

Speech Issues

Limb Usage

* Height

* Current Weight

* Weight Prior to First Symptom

* Assistive Devices Being Used

Additional Health History

Surgeries in Past 10 years

Tobacco Use

Current Alcohol Usage if Applicable

Exposure to Toxic Substances in work, sports or Other (please describe)

Medications and Supplements

Allergies

History of Neurological Disease in your Family

Your Comments/Concerns

ALS Worldwide

Patient Online Profile

Stephen and Barbara ByerFounders and Co-Executive Directors ALS Worldwide

Stephen and Barbara Byer
Founders and Co-Executive Directors
ALS Worldwide