ALS Clinical Trial Eligibility Assessment Questionnaire
Complete this brief questionnaire to assess your potential eligibility for an ALS clinical trial. Please answer all questions as accurately as possible.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you been diagnosed with ALS (Amyotrophic Lateral Sclerosis) by a healthcare professional?
*
Yes
No
Unsure
Approximate date of first ALS symptom onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which of the following best describes your current ALS symptoms?
*
Mild (minimal impact on daily activities)
Moderate (noticeable impact, but independent)
Severe (significant assistance required)
Other / Not sure
Have you participated in any ALS clinical trial in the past 12 months?
*
Yes
No
Are you currently taking any treatments or medications for ALS?
*
Yes
No
If yes, please list current ALS treatments or medications (optional)
Please rate your ability to perform daily activities (such as walking, eating, speaking) over the past week.
*
No difficulty
1
2
3
4
Unable to perform
5
1 is No difficulty, 5 is Unable to perform
Please provide any additional information relevant to ALS clinical trial eligibility (optional)
Submit Assessment
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