ALS Information Form

  • Date Format: MM slash DD slash YYYY
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  • EMERGENCY CONTACT

    In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.
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  • MEDICAL HISTORY

    (once or more a week)
    (once or more a week)
  • Has anyone in your family history been diagnosed with ASL?

  • List name and age when diagnosed.
  • List name and age when diagnosed.
  • List name and age when diagnosed.
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  • ALS/MND Clinical Information

  • FUNCTIONAL STATUS

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  • DENTAL HISTORY

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  • LIFESTYLE

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  • PERSONALITY

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    Below is a collection of phrases that can describe some aspects of a person’s personality. For each item, selectbthe option that best indicates how much you agree with the statements as they apply to you. Please select the option that would have applied to you BEFORE your ALS/MND diagnosis. Rate on a scale of 1-10.

    1 Strongly disagree - 10 Strongly Agree

     

  • Please enter a number from 1 to 10.
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  • &nbps;

    Please select the option that would have applied to you AFTER your ASL/MND diagnosis. Rate on a scale of 1- 10

    1 Strongly disagree - 10 Strongly Agree

     

  • Please enter a number from 1 to 10.
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  • EXERCISE

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  • EATING HABITS

  • Caffeine Consumption

  • Alcohol Consumption

  • Tobacco Use

  • 7 Day Journal: Please describe your daily diet intake



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