Patients as Partners Profile Entry Form

First Name: (required)

Middle Initial:

Last Name: (required)

Street Address: (required)

City: (required)

[State:]
-- select state --AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

ZIP:

Country (If other than U.S.):

Email: (required)

Phone:

Please tell us about your CMT type and your CMT experience.

How does CMT affect you and/or your family? (Select all that apply.)
I have CMT.
My spouse has CMT.
I have a child/children with CMT.
I am the child of a parent with CMT.
We have no family history of CMT; I, or my spouse or child is the first to have it.

Have you or has someone in your family had a genetic test for CMT?
YesNo

Did the genetic test confirm the CMT type and subtype?
YesNo

Please select your CMT type: -- select CMT type --CMT Type 1CMT Type 2CMT Type 4CMT Type XHNPPI Don't Know

Please select your CMT subtype: (required) -- select CMT subtype --1A1B1C1D1E1F1X2A2A2B2B2C2D2E2F2G2I2J2K2L2M2N2O2P2Q4B4B14B24B34C4D4E4F4G4H4JX1 (Same as 1X)X2X3X4X5X6Undiagnosed/Unknown

Have you or has someone in your family been evaluated and/or treated at a CMTA Center of Excellence?
YesNo

Have you or has someone in your family joined the INC Rare Diseases Clinical Research Network (RDCRN) Contact Registry?
YesNo

Have you or has someone in your family joined INC Study 6601: Natural History Evaluation of Charcot Marie Tooth Disease?
YesNo

Please let us know how we can keep you up to date with the latest news on research about your CMT type, as well as other news and information from the CMTA.

Yes. Please send me CMTA eNews with information about research on my type of CMT and opportunities to participate.

If I'm not already signed up to receive CMTA eNews, please sign me up to receive eNews about: (Select all desired categories.)
Events and Webinars
News and Resources
Research Updates