Patient History

One of the goals of ALS of Utica is to research the high numbers of ALS patients in the Oneida and Herkimer County area and gather data for the last 10 to 20 years.  One way to do that is to have a database of past and present ALS patients, if you are an ALS patient or know of an ALS patient, please help us to get this information into our database.  We are learning that our area seems to have high numbers of this disease, but no one seems to have a solid statistic.  This information will be used to get the attention needed for our area and ALS. All information will be held in strict confidence, unless otherwise specified below.  

Name of ALS Patient:
 
Current and Past Addresses: 
(please list most current first)

Number of years at each residence

Water Source

Farm located within
a five mile radius
     Well Water
City Water		 Crops Farm
Livestock Farm
     Well Water
City Water		 Crops Farm
Livestock Farm
     Well Water
City Water		 Crops Farm
Livestock Farm
     Well Water
City Water		 Crops Farm
Livestock Farm
     Well Water
City Water		 Crops Farm
Livestock Farm
     Well Water
City Water		 Crops Farm
Livestock Farm
     Well Water
City Water		 Crops Farm
Livestock Farm
     Well Water
City Water		 Crops Farm
Livestock Farm
Place of Birth (City, State):
Date of Birth:
Date of ALS Diagnosis:
Date Deceased (if applicable):
 Job History of Occupations: Start Date End Date Number of Years
 
 
 Military Service: Start Date End Date Number of Years
 
 
 
History of Traumatic Injuries (especially to vertebra), Burns, Electric shock, etc:
Possible exposure to Pesticides or Fertilizers (explain):
Possible exposure to Heavy Metals (lead, mercury, etc):
Contact Person, if other than patient:
Phone:
Email:
Contact Address if different from above:
Family History of diseases: ALS, Multiple Sclerosis, Parkinson's, Huntington's Chorea, Alzheimer's,
Cancer, Diabetes, Polio, Dementia, etc:
Comments:

Many ALS patients and family members like to share their stories and stay in touch with other ALS patients and family members.  Please select the appropriate option below.


 

This information may be shared with the ALS Community.
Please keep my information confidential and for research purposes only.

 
 


Thank you

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