Preliminary Information

Hello! Welcome to the Stepwise Patient Advocacy questionnaire to introduce yourself prior to our first encounter.

Note:  All information provided here is protected and will not be shared with any other person or entity.

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* 1. Contact Information

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* 2. Are you the patient, or are you calling on behalf of someone?

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* 3. If someone else, what is your relationship to that person?

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* 4. What is the primary issue you’re seeking help with? Please select from the following:

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* 5. What other help are you looking for? Select all that apply.

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* 6. What have you/they been diagnosed with? Please include the exact medical term for your condition/s, obtained from the physician.

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* 7. When were you/they diagnosed with this condition?

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* 8. Any other details you think I should know?

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* 9. How did you find Stepwise Patient Advocacy?

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