Hospice Survey for ALS Patients and Caregivers

General Information and Expectations Prior to Hospice

Are you a caregiver, patient, other?

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* 1. Are you a caregiver, patient, other?

If a caregiver, what is your relationship to the pALS (patient with ALS)?

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* 2. If a caregiver, what is your relationship to the pALS (patient with ALS)?

When was pALS diagnosed? (MM/YY)

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* 3. When was pALS diagnosed? (MM/YY)

What county do you reside in?

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* 4. What county do you reside in?

What was the age of pALS at diagnosis?

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* 5. What was the age of pALS at diagnosis?

What insurance carrier does/did the pALS have?

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* 6. What insurance carrier does/did the pALS have?

Are/Were you seen at an ALS clinic?

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* 7. Are/Were you seen at an ALS clinic?

If yes, what clinic do/did the pALS go to for care?

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* 8. If yes, what clinic do/did the pALS go to for care?

Is/Was pALS in hospice care?

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* 9. Is/Was pALS in hospice care?

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