CMT2A Focus Group Survey

CMT2A Focus Group Survey

Please tell us about your willingness and availability to participate in a CMT2A focus group on July 22 or 23.

First Name: (required)

Last Name: (required)

Email: (required)

Phone:

Do you have CMT2A?
YesNo

If yes, has your diagnosis been confirmed by genetic testing (of you or another family member), or is it based only on clinical examination (physical exam and/or EMG/NCS)?
By Genetic TestingBy Clinical Examination

Please tell us your current age, age at onset/appearance of symptoms, and age at diagnosis.

Current Age:
--current age--123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899

Age at Onset:
--onset age--123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899

Age at Diagnosis
--diagnosis age--123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899

Are you available on either July 22 or July 23? (You may choose either or both.)
July 22July 23

Do you have access to the internet?
YesNo

Do you have a device (computer, laptop, smart phone, tablet) with a camera?
YesNo

Are you comfortable talking about your journey with CMT2A (symptoms, burdens, needs, etc.)?
YesNo

Are you willing to share input with the team of researchers as they prepare for clinical trials?
YesNo

Are you willing to sign a confidential non-disclosure statement?
YesNo

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