Spinal Muscular Atrophy Clinical Trial Eligibility Assessment Questionnaire Form
Spinal Muscular Atrophy Clinical Trial Eligibility Assessment Questionnaire
What is your age group?
*
Under 2 years
2–12 years
13–18 years
19–40 years
Over 40 years
Has a healthcare professional ever discussed or suggested a diagnosis of Spinal Muscular Atrophy (SMA)?
*
Yes
No
Not Sure
Which of the following best describes your current level of mobility?
*
Able to walk independently
Able to walk with assistance
Use a wheelchair or similar device
Unable to walk or move independently
Have you previously participated in a clinical trial for Spinal Muscular Atrophy?
*
Yes
No
Not Sure
Which of the following best describes your respiratory support needs?
*
No respiratory support needed
Occasional non-invasive support (e.g., BiPAP/CPAP)
Regular non-invasive support
Invasive ventilation (e.g., tracheostomy)
Please select any of the following treatments you have received for SMA (select all that apply):
Nusinersen (Spinraza)
Onasemnogene abeparvovec (Zolgensma)
Risdiplam (Evrysdi)
None of the above
Other
How would you rate your overall health status in the past month?
1
2
3
4
5
Are you willing and able to attend study visits at a clinical site if eligible?
*
Yes
No
Not Sure
Please indicate any additional information you would like to share regarding your eligibility or participation interest:
Submit Assessment
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