Patient Registration

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Patient Registration

Section 1: SMA Patient Information:
1.Name of Patient
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*
2. Date of Birth
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*
3. Sex
MaleFemale
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*
4. SMA Type
Type1Type2Type3Type4
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*
5. Do you have Genetic Test Report
YesNo
Please select one option.
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If You Wish to get Genetic test done, contact CureSMAIndia - info@curesmaindia.org | +91 78785 51885
*
6. Please upload the Genetic Test Report
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Invalid file selected.
Invalid file selected.
7. SMA confirmed by (Genetic test)
SMN 1 deletionMuscle biopsyClinically by DoctorAny other
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please specify
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8. No. of SMN 2 copies
0 copy1 copy2 copies3 copies4 copies5 or more copiesDo Not Know
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Do You Wish to Know SMN 2 Copies number ? Then Contact - info@curesmaindia.org | +91 78785 51885
9. Contact No
Fathers Number
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Mothers Number
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*
SMA Patients self Contact Number
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Guardians Contact Number
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10. Current Address
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11. City/town/village of Residence
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12. State of Residence
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13. Permanent address (mention only if it is different than above current address)
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*
Pin Code
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Section 2: SMA Patient's Present Condition To be updated every six months:
In following section, please update present condition of your SMA child/patient
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14. Ambulatory/non-ambulatory (Walking abilities)
Can walk independentlyCan walk with orthotic supportCan stand independentlyCan stand with orthotic supportCan sit independentlyCan sit with support (spinal brace)Can sit with support (any other support)Cannot sit at allNot applicable ( Child is below one year age. )
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*
15. What is the weight of SMA patient?
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*
16. Breathing condition: Is SMA Patient able to breathe comfortably?
YesNo
Please select one option.
Please enter valid data.
*
Non-invasive ventilation (BiPAP) dependency
YesNo
Please select one option.
Please enter valid data.
*
17. Invasive ventilation (Tracheostomy) dependency
YesNo
Please select one option.
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a) When was the Tracheostomy surgery done ?
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b) In which Hospital?
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c) Contact details of Doctor/Surgeon-Email/Phone Number ?
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d) Contact details of Doctor/Surgeon-Email/Phone Number ?
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*
18. Feeding tube (G-tube/NG-tube) dependency
YesNo
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Please enter valid data.
When was the G-Tube/NG Tube surgery done ?
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In which Hospital?
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By which Doctor/surgeon?
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Contact details of Doctor/Surgeon-Email/Phone Number ?
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*
19. Spine condition (Scoliosis of spine) - Has spine/scoliosis surgery been done?
YesNoNot Applicable
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a) In which year?
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b) By which Doctor/spine Surgeon?
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c) In Which Hospital ?
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d) In case of scoliosis/bent spine, does the SMA Patient use spinal brace?
YesNo
Please select one option.
Please enter valid data.
Please Mention in brief about what type of spinal brace & name & contact of othotic/bracing specialist who made the brace.
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
e) Do you know SMA Patient’s Scoliosis cobb angle?
YesNo
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f) Do You Need Help ?
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g) Please Mention Cobb angle
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h) Name and Contact details of Spine Doctor who helped you to measure Cobb angel -
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20. Other deformities if Any
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21. Current SMA Management
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a) Is your child undergoing regular physiotherapy session?
YesNo
Please select one option.
Please enter valid data.
Please Mention Name & Contact of Your Physiotherapist .
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
b) Are You Following SMA Specific diet plan for your child ?
YesNo
Please select one option.
Please enter valid data.
Please Mention Briefly about diet plan & Name & Contact of your Nutritionist .
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
22. Does SMA Patient use Wheelchair?
YesNo
Please select one option.
Please enter valid data.
a) Wheelchair
Pediatric manualPediatric motorizedManualMotorized
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
23. Name Your Regular Doctor
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*
24. Name Your Regular Hospital
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25. SMA Patients regular monitoring parameters To be updated every six months:
*
Date On Which below information is updated.
Please select date.
Invalid Date.
*
a) Chop Intend Score (Type of Muscle charting)
YesNoNot applicableDont Know
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Mention Chop Intend score
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
Hammersmith Scale Score (Type of Muscle charting)
YesNoNot applicableDont know
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Mention Hammersmith score
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
Assessment of motor performance of upper limbs - RULM Score
YesNoNot applicableDont Know
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If yes, mention RULM score
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
Lung function OR Pulmonary Function test score
YesNoNot applicableDont Know
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Mention % of lung function
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
Cobb Angle in case of scoliosis  (Bending of spine)
YesNoNot applicableDont Know
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Mention degree of cobb angle
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
26. Has your SMA child received any SMA medicine till now?
YesNo
Please select one option.
Please enter valid data.
A(0) Spinraza through SIPHAP program
YesNo
Please select one option.
Please enter valid data.
A(i) Name of Doctor & Hospital
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A(ii) Are you seeing any improvement in your child? Even small improvements are counted
Very minor improvementSatisfactory improvementSubstantial improvementNo Improvement
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A(iii) Are you continuing with Physiotherapy post medicine access?
YesNo
Please select one option.
Please enter valid data.
A(iv) Are you continuing with proper Nutritious Diet post medicine access?
YesNo
Please select one option.
Please enter valid data.
B(0) ZolgenSMA through MAP program
YesNo
Please select one option.
Please enter valid data.
B(i) ZolgenSMA through GMAP OR Crowdfunding .
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B(ii) Are you seeing any improvement in your child? Even small improvements are counted
Very minor improvementSatisfactory improvementSubstantial improvementNo Improvement
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B(iii) Are you continuing with Physiotherapy post medicine access?
YesNo
Please select one option.
Please enter valid data.
B(iv) Are you continuing with proper Nutritious Diet post medicine access?
YesNo
Please select one option.
Please enter valid data.
C(0) Risdiplam through CUP,
YesNo
Please select one option.
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C(i) Name of Doctor & Hospital
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C(ii) Are you seeing any improvement in your child? Even Small improvements are counted
Very minor improvementSatisfactory improvementSubstantial improvement
Please select one option.
Please enter valid data.
C(iii) Are you continuing with Physiotherapy post medicine access?
YesNo
Please select one option.
Please enter valid data.
C(iv) Are you continuing with proper Nutritious Diet post medicine access?
YesNo
Please select one option.
Please enter valid data.
Section 3: SMA Patient Occupation Information
27. Patient Education/Occupation
Not enrolled in school as child cannot sitNot enrolled as child is too small/not eligible to go to schoolNot enrolled due to society/family issuesStudying in special schoolStudying in government (regular) schoolStudying in private (regular) schoolStudying in College/UniversityTaking Home SchoolingWorking (government job)Working (private job)Working (outside India)Self employed/Own BusinessWorking with NGOWorking for social causeJoined family Business
Please select one option.
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a) Does SMA Patient have Health Insurance ?
YesNo
Please select one option.
Please enter valid data.
Central Government Health Scheme (CGHS)Autonomous Institute covered under Central Government Health Scheme (CGHS)Public Sector Undertaking covered by Central or state Govt OR own PSU reimbursement schemeDefense Services covered by Central or state Govt OR own Defense Service reimbursement schemeRailways Services covered by Central or state Govt OR own Railway services reimbursement schemeState Government Health Insurance (SGHI)Employees State Insurance Corporation (ESIC)Private Health insuranceNone of the above
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Name of Private Health Insurance.
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Do You Need Help
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Do You Need help Support ? Contact - info@curesmaindia.org | +91 78785 51885
*
28. Hobbies of SMA Patient? To be updated every year.
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Section 4: Parents/Guardian’s back ground Information
29. Name of Father/Guardian
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30. Father Education?
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31. Father Occupation
State Government ServiceCentral Government ServicePublic Sector UndertakingDefense ServiceRailways ServicePrivate ServiceBusinessConsultant/Self employedFull time CaregiverPart time work and part time CaregiverRetired from Central Government ServiceRetired from State Government ServiceRetired from Private ServiceAny other
Please select one option.
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Organization Name  (whether in service OR own business)
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32. Is the Father covered under any health reimbursement scheme?
Central Government Health Scheme (CGHS)Autonomous Institute covered under Central Government Health Scheme (CGHS)Public Sector Undertaking covered by Central or state Govt OR own PSU reimbursement schemeDefense Services covered by Central or state Govt OR own Defense Service reimbursement schemeRailways Services covered by Central or state Govt OR own Railway services reimbursement schemeState Government Health Insurance (SGHI)Employees State Insurance Corporation (ESIC)None of the above
Please select one option.
Please enter valid data.
a) If You have Health Insurance,does it cover SMA (Genetic disease) ?
YesNo
Please select one option.
Please enter valid data.
Name of the Health Insurance Company Covering SMA (genetic) disease)
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33. Name of Mother/guardian
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34. Mother Education
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35. Mother Occupation
State Government ServiceCentral Government ServicePublic Sector UndertakingDefense ServiceRailways ServicePrivate ServiceBusinessConsultant/Self employedFull time CaregiverPart time work and part time CaregiverAny other
Please select one option.
Please enter valid data.
Organization Name (whether in service OR own business)
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36. Is the Mother covered under any health reimbursement scheme?
Central Government Health Scheme (CGHS)Autonomous Institute covered under Central Government Health Scheme (CGHS)Public Sector Undertaking covered by Central or state Govt OR own PSU reimbursement schemeDefense Services covered by Central or state Govt OR own Defense Service reimbursement schemeRailways Services covered by Central or state Govt OR own Railway services reimbursement schemeState Government Health Insurance (SGHI)Employees State Insurance Corporation (ESIC)None of the above
Please select one option.
Please enter valid data.
37. Total Household income (Annual) from all sources ( In Indian rupees)
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(In Words)
( income In numbers)
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38. If you have Insurance coverage in case of Hospitalization of SMA patient? Please tick what type? (Choose only one option) (Skip if already answered in Q33 OR Q37)
Employee State Insurance CorporationCentral government Health Scheme (CGHS)Public Sector Unit(PSU)RailwaysArmyPrivate Health Insurance such as New India Insurance, TATA AIG, Star Health InsuranceI Do Not have Insurance
Please select one option.
Please enter valid data.
Any other, pls specify
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39. If not covered in Insurance, then how do you manage medical emergency, for your SMA child in case of hospitalization? (Choose option/s as applicable) ( Answer only if Q33, Q37 and Q39 last option 'I Do Not Have Insurance' selected )
Own expensesSupport from hospitalSupport from other charitable trust/NGOCooperative societyLoan
Please select one option.
Please enter valid data.
Any other, pls specify
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40. What is your main source of information on the disease SMA? (Choose option/s as applicable)
From my child’s DoctorInternet/self studyMedia/Newspaper/social mediaFrom CureSMA India
Please select one option.
Please enter valid data.
Any other, Please Specify
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41. Are you a registered member of Cure SMA Foundation of India (If not still registered, you may do so by visiting www.curesmaindia.org)
YesNo
Please select one option.
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42. Do you know your membership number?
YesNo
Please select one option.
Please enter valid data.
Please mention here
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43. Are you a registered member of any other Patient group/s related to SMA or any other rare diseases?
YesNo
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44. If yes, please specify name of such Patient group (It is absolutely okay even if you are registered, but kindly mention the facts here)
Name/s
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Location of the Patient Group/s
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45. Do you pay CureSMA India membership fees regularly?
YesNo
Please select one option.
Please enter valid data.
How frequently? (Monthly/Quarterly/Six Monthly/Yearly)
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When was the last you paid . Approximate month/date.
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If NO,Please state reason
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46. Do you participate in activities/meetings regularly?
YesNo
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Please enter valid data.
If Yes, Name few activities you participated.
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If No, What stops you from participating?
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Please give two suggestions how we can help you participate better
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47. Are you active on social media?
YesNo
Please select one option.
Please enter valid data.
If Yes, Name which social media are you active on?
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If No, Please state reason.
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Please give two suggestions how we can help you to be more active on social media
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48. Does SMA patient have any NON SMA sibling? (Information may be updated once in a year)
Not applicable, SMA Patient is single childBrotherSister
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Age of sibling?
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Occupation of sibling?
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Any other information (eg twins, two sisters, two brothers etc)?
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49. Total number of SMA patients in the family?
1234
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If more than one, have you registered all others on www.cresmaindia.org?
YesNo
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50. Has there been any SMA related death in your family before?
NoYes
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If yes, who? When?
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51. Remarks: Any other Information you would like to share which is not covered in above questionnaire ?
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Final Registration
*
Email Address for registration
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Password for registration
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    Strength: Very Weak
    Acceptance of 'Hold Harmless declaration'
    I hereby declare and authorise CureSMA India and its members to share information provided by me to any institution, agency, company, hospital or clinical organisation for the purpose of providing patient information to any of the above institutions/organisations. I do not have any objections to share this information that has been provided above by me to CureSMA India. The information shared by me includes but not limited to - patient information, images, videos, contact details and/or any clinical data. This authorisation is not conditional under any circumstances. My acceptance of this 'Hold Harmless declaration' should be treated as a consent to indemnify CureSMA India from any liability (legal, commercial or penal) arising out of the sharing of the information that has been provided by myself.
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