VN_Th_ALS_Medicalreport_no_no_Eng

Discover the available treatment options following an ALS diagnosis and how the progression of the disease can be slowed down with effective medical care.

Submit the form to speak to an ALS Treatment specialist

Patient Representative

Patient Representative(Required)

Patient Information

Patient Name(Required)

Patient Phone(Required)

Patient Email(Required)

Address

Street Address Address Line 2 City State / Province ZIP / Postal Code Country

Date of Birth

DD slash MM slash YYYY

Patient's Height

Patient's Weight

Patient's Gender

Male

Female

Patient's first language

Patient's second language

Contact Person Information (if different from patient)

Contact Person's Name

Contact Person's Email

Contact Person's Phone Number

Medical Conditions & History

Primary Diagnosed Condition (Ex. C6 Spinal Cord Injury)

Date of Diagnosis

DD slash MM slash YYYY

Current Symptoms

Treatment History (Please include past & present treatments, medications, and rehabilitation programs used in treating your primary condition.)

Secondary Diagnosed Condition (Ex. Diabetes)

Additional Diagnosed Conditions and/or Relevant Family Medical History

Past Surgeries for Any of Your Conditions

Medical Questions

Please answer the questions about the patient's condition in as much detail as possible. Every question requires an answer, so if you are unsure please just choose "Unsure".

Does the patient have any communicable illnesses such as HIV, Hepatitis, Tuberculosis (TB), Herpes, or any other sexually transmitted diseases?

Yes

Unsure

Does the patient have, or has the patient ever had, a malignant or benign cancerous tumor?

Yes

Unsure

Does the patient have hypertension (high blood pressure) or hypotension (low blood pressure)?

Yes

Unsure

Does the patient currently have any bedsores?

Yes

Unsure

Does the patient currently have any ulcers?

Yes

Unsure

Does the patient have shortness of breath or difficulty breathing?

Yes

Unsure

Does the patient currently require the use of a ventilator?

Yes

Unsure

Has the patient undergone a tracheotomy?

Yes

Unsure

Does the patient require suctioning to keep their airways clear?

Yes

Unsure

Does the patient require the use of supplemental oxygen?

Yes

Unsure

Does the patient have any metal plates or rods in their body?

Yes

Unsure

Does the patient have a pacemaker?

Yes

Unsure

If yes, please explain why and what type.

Does the patient have a continuous-medication pump?

Yes

Unsure

Does the patient have a feeding tube?

Yes

Unsure

Has the patient received at least one vaccination in the past three months?

Yes

Unsure

Hidden

File Doctor’s Reports

Please attach any doctor’s reports, medical test results, and discharge summaries that pertain to the patient’s Medical Conditions & History.PLEASE NOTE: Large files may require extra time to upload, so after you’ve clicked “SUBMIT” below, please do not close your browser window until you’ve received the message confirming a successful submission.

Hidden

File Upload

Drop files here or

Accepted file types: jpeg, jpg, gif, png, pdf, rar, zip, iso, Max. file size: 1,000 MB.

Please describe the type of results the patient is hoping to achieve with this treatment.

How did the patient find out about this treatment?

If accepted to the program, on what date would the patient like to start their treatment?

Potential Improvements

Motor function
Balance and Coordination
Neuropathic Pain
Fatigue

Tremors
Speech
Swallowing
Reduced Speed of Disease Progression

ALS Treatment Testimonials

Contact an ALS Treatment Specialist Now

Legal Notice
Site Map
Privacy Policy

alstreatment.com is owned by Verita Neuro Pte. Ltd. Verita Neuro provides access to progressive, responsible healthcare to increase the quality of life. Verita Neuro partners with leading-edge, next-generation treatment providers, unique products and services, that are integrative, safe and effective. Verita Neuro is not a treatment provider.