ALS Patient Registry

Patient Registry

An ALS Diagnosis can be overwhelming, confusing, and frightening. If you have received an ALS diagnosis, you probably have A LOT of questions about the disease, the prognosis, and the treatments available. Our staff collaborates with medical professionals who specialize in ALS to coordinate medical care and community resources to address your family’s un-met needs. We educate on disease progression and symptom management so you can make informed decisions about your care, we provide equipment that maintains safety and independence free of charge, and we help create a community of supportive peers, ensuring that your family does not face these challenges alone. We invite you to register with us so we can offer free programs and services to help you and your family navigate these challenges.

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I would like to receive e-mail from ALS Arizona
I would like to receive postal mail ALS Arizona
Primary Caregiver
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Name of Neurologist
Current Symptoms
Insurance carrier
How did you hear about us?

Additional Information

The ALS Arizona collects statistical information from families affected by ALS to be used for grant reporting purposes only. This voluntary information will remain confidential and your responses do not affect your ability to receive services.
Please select the racial group or groups with which the person with ALS most closely identifies. Check as many as apply:
Please indicate the ethnicity of the person with ALS:
Marital Status
Marital Status of Person with ALS:
Household Size
Number of Individuals in Household:
Employment Status
Current Employment status of person with ALS:
Spouse/SO Employment Status
Current Employment status of spouse/significant other: