First Name

Last Name

Country

Address

Address Line 2

City

State/Province

ZIP/Postal Code

Phone

I would like to be notified about drug trials and other research opportunities YesNo

Are you a patient with FSHD?

Gender

Date of Birth

Your age at onset of symptoms

Your age at diagnosis

Have you had genetic testing? What were the results?

Do you have genetically related parents, siblings or children with FSHD?

Do you have other genetic relatives - NOT parents, siblings, or children -- 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

I am interested in (check all that apply) EducationPeer SupportResearchClinical TrialsFundraisingVolunteering

I would like the FSHD Toolkit YesNo

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