CMT Disease Assessment Survey
Please complete this survey to help assess the symptoms and impact of Charcot-Marie-Tooth (CMT) disease.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Have you been diagnosed with Charcot-Marie-Tooth (CMT) disease by a healthcare professional?
*
Yes
No
Not sure
Please rate the severity of the following symptoms related to CMT disease:
*
Rows
None
Mild
Moderate
Severe
Muscle weakness in legs
1
2
3
4
Muscle weakness in arms/hands
5
6
7
8
Loss of sensation in feet
9
10
11
12
Loss of sensation in hands
13
14
15
16
Balance difficulties
17
18
19
20
Foot deformities (e.g., high arches, hammertoes)
21
22
23
24
Muscle cramps or pain
25
26
27
28
How would you rate your ability to perform the following activities?
*
Rows
No difficulty
Some difficulty
Great difficulty
Unable to perform
Walking unaided
29
30
31
32
Climbing stairs
33
34
35
36
Using hands for daily tasks
37
38
39
40
Standing for 10 minutes
41
42
43
44
Participating in physical activities
45
46
47
48
How often do you experience pain or discomfort due to CMT disease?
*
Never
Occasionally
Frequently
Always
On a scale of 1 to 10, how would you rate your overall quality of life? (1 = very poor, 10 = excellent)
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
Have you used any assistive devices due to CMT disease? (Select all that apply)
None
Ankle-foot orthosis (AFO)
Walking cane
Walker
Wheelchair
Other
Please share any additional comments or information about your experience with CMT disease.
Submit Assessment
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