First Name
Last Name
Email
Country United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d’Ivoire Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Viet Nam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Address
Address Line 2
City
State/Province AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT
ZIP/Postal Code
Phone
I would like to be notified about drug trials and other research opportunities YesNo
Are you a patient with FSHD? yes no
Gender
Date of Birth
Your age at onset of symptoms
Your age at diagnosis
Have you had genetic testing? What were the results? I have not had a genetic test FSHD Type 1 FSHD Type 2 FSHD Type 1 and FSHD Type 2 FSHD - unsure of type I'm not sure
Do you have genetically related parents, siblings or children with FSHD? I have at least one parent, sibling, or child with FSHD I do not know of any parent, sibling, or child with FSHD
Do you have other genetic relatives - NOT parents, siblings, or children -- with FSHD? I have at least one genetic relative (apart from my parents, siblings, or children) with FSHD I do not know of other genetic relatives with FSHD
I am a ... (check all that apply) Relative of a PatientCaregiverPhysicianResearcherPhysical TherapistOther Clinician
I would like to join a local chapter of the FSHD Society Arizona Chapter Atlanta Chapter Bay Area Chapter CenTex Chapter Chicagoland Chapter Colorado Chapter Columbus Chapter Connecticut Chapter Daytona Beach Chapter East Tennessee Chapter Greater Philadelphia Chapter Idaho Chapter Kansas City Chapter Los Angeles Chapter --Member at Large-- Mid-Atlantic Chapter New England Chapter New York City Chapter North Carolina Chapter Pacific Northwest Chapter Sacramento Chapter San Diego Chapter South Carolina Chapter Southwest Florida Chapter St. Louis Chapter Tampa Chapter Utah Chapter Western Pennsylvania Chapter Wisconsin Chapter
I am interested in (check all that apply) EducationPeer SupportResearchClinical TrialsFundraisingVolunteering
I would like the FSHD Toolkit YesNo
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