Own Your Path Screening Survey

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 NHF or our program partner NexJ to contact you regarding next steps.

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* 1. How old are you?

Younger than 18

18-23

24-29

30-39

40-49

50-59

60-69

70-79

80-89

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* 2. What gender do you identify with the most?

Female

Male

Trans male (female to male)

Trans female (male to female)

Non-binary

Intersex

Prefer not to answer

Prefer to Describe

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* 3. How did you hear about this program?

HTC

Chapter

Social Media

Friend/Family Member

Webinar

Podcast

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

Hemophilia A

Hemophilia B

Other bleeding disorder

I do not have a bleeding disorder

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* 5. What was the approximate date of your diagnosis?

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* 6. Is your Hemophilia considered:

Mild

Moderate

Severe

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* 7. Where do you currently live?

United States or US Territory

Other

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* 8. Which state do you live in (if you are in the U.S.A)? Which country do you live in if you are outside of the U.S.A.?

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* 9. Which HTC do you use?

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* 10. If you don't go to an HTC, which provider do you see to manage your bleeding disorder?

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* 11. Which best describes your prescribed treatment schedule?

Prophylaxis (aka “do prophy” or treat on a regular basis to prevent bleeding episodes and expect to do so for the foreseeable future)

Prophylaxis (aka “do prophy” or treat on a regular basis to prevent bleeding episodes and will do so for an extended period (sports season, procedure, etc.) but not forever

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

I am not sure

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

Standard half-life factor products (e.g., Advate, Benefix, etc.)

Extended half-life factor products (e.g., Eloctate, Alprolix, etc.)

Non-Factor treatment product (e.g., Hemlibra)

Clinical trial study drug

No product, received Gene Therapy from a clinical trial

I am not sure

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* 13. In the last 3 months, how often have you followed your prophy treatment plan as prescribed by your health care provider (treated with the correct dose and on the prescribed day)?

Own Your Path Screening Survey

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* 1. How old are you?

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* 2. What gender do you identify with the most?

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* 3. How did you hear about this program?

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

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* 5. What was the approximate date of your diagnosis?

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* 6. Is your Hemophilia considered:

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* 7. Where do you currently live?

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* 8. Which state do you live in (if you are in the U.S.A)? Which country do you live in if you are outside of the U.S.A.?

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* 9. Which HTC do you use?

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* 10. If you don't go to an HTC, which provider do you see to manage your bleeding disorder?

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* 11. Which best describes your prescribed treatment schedule?

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

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* 13. In the last 3 months, how often have you followed your prophy treatment plan as prescribed by your health care provider (treated with the correct dose and on the prescribed day)?

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* 14. Your First and Last Name

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* 15. Your Phone Number

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* 16. Your email address

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* 17. Please confirm your email address