Patient Questionnaire

Date of Birth *

MM

DD

YYYY

Gender

Male

Female

Date of diagnosis

MM

DD

YYYY

Date of Onset of Symptoms

MM

DD

YYYY

Have you been diagnosed with familial or sporadic ALS?

Familial ALS

Sporadic ALS

What is your formal diagnosis level?

Possible

Probable

Definite

What is the usual intensity of your excercise routine?

Light

Moderate

Moderate to Intense

How would you describe your life history of antibiotic use? *

0 or almost never

1-3 times a year

4-6 times a year

More than 6 times a year

Do you experience fasciculations?

Yes

No

Have you been tested for SOD1 gene mutation and if yes, do you have the SOD1 gene mutation? *

I have been tested and have the SOD1 mutation

I have been tested and do NOT have the SOD1 mutation

I have not been tested for the SOD1 mutation

Do you currently take Rilutek® or Radicava®?

Rilutek® (riluzole)

Radicava®

Both

Neither