Follow-up Form – Amyotrophic Lateral Sclerosis (ALS) – Throne Biotechnologies

Your First Name

Your Last Name

Your Address

City

State/Province

Zip/Postal

Country

Your Address

Your Phone

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Your email address

Today's Date

Your Birth Date

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Your Age In Years

File Name

Sex

Male

Female

What was your usual weight, in pounds, before the onset of your autoimmune condition?

Your Weight (in pounds)

Your Height in Feet

And Inches

How many months has it been since your initial stem cell educator treatment?

List All Medications That You Take For Your ALS, Enter "None" If None

List any other autoimmune conditions that you believe that you have.

Enter The Name, Address, Phone Number, And Email Address Of The Doctor And/Or Clinic That Provides Your ALS Care, Enter "None" If None.

Are You Employed At This Time?

Yes, Full Time (Greater Than 30 Hours Per Week)

Yes, Part Time (Between 20 and 30 Hours Per Week)

Yes, Part Time Less Than 20 Hours Per Week)

Retired

Disabled, Unable To Work

Not Retired But Not Working At This Time

Do You Have Or Need A Caretaker And, If So, Who Supplies That Care?

I can function independently

I live with a family member or friend who provides caretaking services for me

Someone comes to my home to provide caretaking services for four or less hours per day

Someone comes to my home to provide caretaking services for eight or less hours per day

Someone comes to my home to provide caretaking services for twelve or less hours per day

One or more caretakers come to my home to provide caretaking services 24/7

I live in a care facility and that care facility provides my caretaking services

List All Other Chronic Illnesses Or Disorders (enter "None" If none)

List All Medications That You Take For Any Reason Other Than ALS, If None, Enter "None."

List All Allergies To Any Drugs Or Anything Else. Enter "None" If None.

Can you raise your right hand and arm straight up?

Yes, even lifting a ten pound hand weight

Yes, even lifting a five pound hand weight

Yes, even lifting a three pound hand weight

Yes, even lifting a one pound hand weight

Yes, but cannot lift any weight

Only half way

I can only lift my right hand up to my shoulder

I cannot lift my right hand up at all

Can you raise your left hand and arm straight up?

Yes, even lifting a ten pound hand weight

Yes, even lifting a five pound hand weight

Yes, even lifting a three pound hand weight

Yes, even lifting a one pound hand weight

Yes, but cannot lift any weight

Only half way

I can only lift my left hand up to my shoulder

I cannot lift my left hand up at all

Required HIPPA Privacy Practices Notice: (Follow link below)

Yes, I have reviewed the HIPPA Privacy Practices Notice

HIPPA Privacy Practice Notice

Email Communication Authorization:

Yes, I give permission for Throne Biotechnology and Its doctors to communicate with me regarding my care by Telephone, Text Message, or Email.

In what ways do you think that your ALS is better or worse now than it was before your stem cell educator therapy?

If you are human, leave this field blank.

Follow-Up Form

Amyotrophic Lateral Sclerosis (ALS)

ALS Specific Questions

Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R)

Follow-Up Form Amyotrophic Lateral Sclerosis (ALS)

ALS Specific Questions

Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R)

Follow-Up Form

Amyotrophic Lateral Sclerosis (ALS)