Survey - Register with Our Chapter

To become eligible for The ALS Association, MN/ND/SD Chapter's programs and services a person must have a diagnosis of ALS, PLS, or PMA and live in our service area. You can register online using this form, or by calling our office at 612-672-0484 or Toll Free at 888-672-0484 and speaking with one of our Care Services staff.

If you complete the online registration, someone from our Care Services Department will contact you with more information.

The following set of questions are about the person diagnosed with ALS.

*1.

Question - Required - Name (First, Middle Initial, Last):

*2.

Question - Required - Address:

*3.

Question - Required - City, State Zip Code:

4.

Question - Not Required - Home Phone Number:

*5.

Question - Required - Cell Phone Number:

*6.

Question - Required - Email Address:

*7.

Question - Required - Date of Birth:

*8.

Question - Required - Date of ALS diagnosis (approximate dates are fine):

*9.

Question - Required - Gender:

*10.

Question - Required - Primary Language:

*11.

Question - Required - Relationship status:

*12.

Question - Required - Do you live alone?

*13.

Question - Required - Spouse/Partner's name (or emergency contact):

Please complete the information below if it is different from above.

14.

Question - Not Required - Address:

15.

Question - Not Required - City, State Zip Code

16.

Question - Not Required - Phone:

17.

Question - Not Required - Email:

*18.

Question - Required - Name of ALS Clinic where you were diagnosed:

(Maximum response 255 chars, approx. 5 rows of text)

19.

Question - Not Required - Name of ALS Clinic you plan to attend (if different from above):

(Maximum response 255 chars, approx. 5 rows of text)

20.

Question - Not Required - Name of Neurologist:

*21.

Question - Required - Are you employed?

22.

Question - Not Required - Job Title:

*23.

Question - Required - Are you a military veteran?

24.

Question - Not Required - If yes, are you connected with your local Veterans Administration?

*25.

Question - Required - Primary Insurance (name of insurer only - we do not need ID numbers):

26.

Question - Not Required - Secondary Insurance:

*27.

Question - Required - Type of ALS:

28.

Question - Not Required - Do you have any issues with the following:

	Speech
	Swallowing
	Breathing
	Mobility
	Self Care
	Cognition

*29.

Question - Required - Height:

*30.

Question - Required - Weight:

31.

Question - Not Required - Current Symptoms:

	Weakness in hands
	Weakness in feet
	Weakness in neck
	Difficulty speaking
	Difficulty walking
	Difficulty with saliva
	Difficulty breathing
	Difficulty swallowing
	Weight loss
	Muscle cramps
	Fasciculations (muscle twitching)

32.

Question - Not Required - Would you like to receive the monthly newsletter from The ALS Association, MN/ND/SD Chapter

Yes

Terms and Conditions

33.

Question - Not Required - To be eligible for our programs and services please click on the terms and conditions above and sign your name below if you agree.