Hospice Survey for ALS Patients and Caregivers

General Information and Expectations Prior to Hospice

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

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

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

* 4. What county do you reside in?

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

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

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

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

* 9. Is/Was pALS in hospice care?

T