Application – Amyotrophic Lateral Sclerosis (ALS) – Throne Biotechnologies

Your Name

First Name

Last Name

Your Address

City

State/Province

Zip/Postal

Country

Your Address

Your Phone

Your email address

Your Birth Date

Your Weight (in pounds)

Your Height in Feet

And Inches

Sex

Male

Female

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 The Reasons For All Hospitalizations Of More Than One Day And The Years In Which They Occurred, Enter "None" If None.

List All Major Surgeries And The Years In Which They Occurred, 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.

List All Vaccinations For Which You Have Records And Age When Vaccinated, Including COVID-19, Enter "None" If None.

ALS Specific Questions

Is your ALS diagnosis confirmed or just suspected?

Confirmed

Suspected

For how many years have you had symptoms of ALS

Less than one

One to two years

Two to three years

Three to four years

Four to five years

Five to six years

More than six years

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.

If you are human, leave this field blank.

Telemedicine Consultation Form

Amyotrophic Lateral Sclerosis (ALS)

ALS Specific Questions

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

Telemedicine Consultation Form Amyotrophic Lateral Sclerosis (ALS)

ALS Specific Questions

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

Telemedicine Consultation Form

Amyotrophic Lateral Sclerosis (ALS)