Own Your Path Screening Survey (New Audiences)

Please complete this survey to see if you meet the requirements for the Own Your Path program. By completing this survey, you are giving consent for NBDF or our program partner NexJ to contact you regarding next steps.

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* 1. How old are you?

Younger than 18

18-29

30-39

40-49

50-59

60-69

70-79

80+

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* 2. Which type of bleeding disorder have you been diagnosed with?

Hemophilia A

Hemophilia B

Von Willebrand Disease

I do not have a bleeding disorder

Other (please specify if you have more than one bleeding disorder)

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* 3. Where do you currently live?

United States or US Territory

Other (please specify)

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* 4. Which best describes your current prescribed treatment schedule?

Prophylaxis (aka “do prophy” or treat on a regular basis to prevent bleeding episodes, may include factor replacement therapy, bispecific antibody therapy, desmopressin, and/or antifibrinolytics)

On-demand (only treat when you have a bleed)

I am not sure

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* 5. What type of treatment product do you currently use?

Standard half-life factor products to treat hemophilia (ex. Advate, Benefix, etc.)

Extended/Ultra half-life factor products to treat hemophilia (ex. Eloctate, Alprolix, Altuviiio, etc.)

Non-Factor treatment product to treat hemophilia(ex. Hemlibra)

Treatment for VWD (ex. Humate-P, VonVendi, Wilate, etc.)

Antifibrinolytic products (ex. tranexamic acid, aminocaproic acid, etc.)

Desmopressin (ex. DDAVP)

Clinical trial study drug (ex. Rebalancing Agents -Anti-TFPI, RNAi)

No product, received Gene Therapy

I am not sure

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* 6. For the last 3 months, what percentage would you give yourself for how well you follow your prophy treatment plan as prescribed by your health care provider (treated with the correct dose and on the prescribed day)?

Never

Some of the time

Usually

Almost Always

Always

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* 7. Your First and Last Name

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* 8. Your Phone Number (by entering your phone number, you give consent for NBDF and/or NexJ to text you regarding the Own Your Path program)

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* 9. Your email address

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* 10. Please confirm your email address

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* 11. How did you hear about this program?

HTC

Chapter

Social Media

Friend/Family Member

Email from NBDF

Webinar

Podcast

Other (please specify)