Register at achondroplasia We have design a questionnaire with the purpose to know better the population connected to achondroplasia.The questionnaire is optional and anonymous.The data obtained will be used for statistical purpose and to understand better the natural history of achondroplasia.Please consider answering.If you would like to take the survey later, you can click at the link at the top "Register at BA". Introduction Patient Caregiver Patient advocate Doctor Therapist Researcher Health consultant Organization Pharmaceutic company User type Please select the type of user that you are. Multiple options available. User type Basic user Patient Caregiver Patient advocate Doctor Therapist Researcher Health consultant Organization Pharmaceutic company What is your knowledge about achondroplasia - Select - Reduced Average High Expert Patient Birth month and year (MM/YYYY) Medical exams Exam - Select - Genetic test X rays MRI CT Blood exam Ultrasound Other Designation Year Add exam Surgeries Surgery - Select - Orthopedic correction Lengthening - legs Lengthening - arms Tonsilectomy Adenoidectomy Ventricular shunt Spinal fusion Cervical decompression Lumbar decompression Ear tubes Other Designation Year Hospital Country Add surgery Medical follow-up Genetics Neurosurgery Neurology ENT Dentistry Pneumology Orthopedics Physiatry Pediatrics Other speciality Designation Speciality Physiotherapy Speech therapy Ocupational therapy Osteopathy Naturopathy Homeopathy Other Designation Clinical center for the majority of the assessments Public Hospital Name Private Hospital Name Clinic Name Member of a patients association Yes No Association name Country Member of other patients association Yes No Other patients association Enrolled in a clinical trial Yes No Designation Date Enrolled in a achondroplasia registry Yes No Designation Caregiver Patient under care:: Year of birth Male/female Male Female Country Social relation with the patient Parent Brother Sister Grandparent Aunt/uncle Friend Institution Other Designation Member of a professional association/committee/network Yes No Association name Country Patient advocate What you advocate for Achondroplasia Bone dysplasias Rare diseases Generic diseases A single case URL Link Other Designation Advocacy webpage When did you start advocating? Doctor Speciality Genetics Neurosurgery Neurology ENT Dentistry Pneumology Orthopedics Physiatry Pediatrics Psychologist Nurse Medical student Nurse student PhD student Other speciality Designation Country of work Work place Public Hospital Name Private Hospital Name Clinic Name University Name Medical research center Name Position Intern Resident Fellow Director of speciality Other Designation Experience with patients with Achondroplasia Number of patients assessed Years of work with patients with Achondroplasia Member of a medical association/committee/network Yes No Associations/committees/networks Therapist Speciality Physiotherapy Speech therapy Ocupational therapy Osteopathy Naturopathy Homeopathy Other Designation Work place Public Hospital Name Private Hospital Name Clinic Name University Name Medical research center Name Experience with patients with Achondroplasia Number of patients assessed Years of work with patients with Achondroplasia Member of a medical association/committee/network Yes No Associations/committees/networks Researcher Field of studies Skeletal dysplasias Genetics Medicine Biology Biochemistry Orthopedics Other Designation Researcher type Academia Private company Member of a professional association/committee/network Yes No Associations/committees/networks Health consultant Health consultant type Individual Company Work experience in Skeletal dysplasias Genetics Medicine Biology Biochemistry Orthopedics Other Designation Organization Area of work and intervention Bone diseases Rare diseases Pediatric diseases Other Designation Type of organization - Select - Association Foundation Network Committee Other Designation Number of members Role - Select - Director Project manager Board member Member Volunteer Other Designation Pharmaceutic company Area of work and intervention Bone diseases Rare diseases Pediatric diseases Other Designation Role - Select - CEO CMO COO Patient advocacy director Project manager Clinical trials director Researcher Pharmacologist Other Designation Your details NOTE: This form is anonymous, these fields are optional, only fill them if you would like us to contact you. Email Country Privacy policy I have read and accept the User Agreement and Privacy Policy Mark Por favor insira o código que vê na imagem. A carregar... Powered by ChronoForms - ChronoEngine.com
