Let's start with some basic patient information.

    Disclaimer: By continuing you acknowledge that the information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Completing this form does not confirm your qualification for a medical ID card. By continuing you agree that we may contact you at the provided email address and telephone number to discuss this qualification survey, potential appointments, and to send other necessary and relevant future communications.

    Please select your medical condition

     

    My condition affects my everyday life

    1: Not at all2: Half the time3: All the time

     

    I can not do the things I enjoy because of my condition

    1: Not at all2: Half the time3: All the time

     

    If I didn’t have this condition, my quality of life would be better

    1: Not at all2: Half the time3: All the time