Welcome to Sign Up Form!

Please insert your information carefully, If needed, ask your family or caregiver for help filling out the registration form.

Personal Information Form

Enter the patient's details carefully

*First Name
*Last Name

*Password

*Confirm Password

*Job
*Phone Number

*

Gender

Female
Male

*

Education

Age range

*

What is your age range?

Under 18 years old (child)
Over 18 years old (adult)

*

Type of disease and date of diagnosis

ALS

MS

Stroke (CVA)

Parkinson

Other Disease

*Date of diagnosis

Speech therapy history

*

Determine your speech therapy status.

Yes

No

Under treatment

Vision and hearing status

*

Vision

Corrected Not corrected Healthy

*

Hearing

Corrected Not corrected Healthy

Description

If there is anything specific about your condition that would affect our research process, please mention it in the box below.

After reviewing the Terms, Privacy Policy, and Research Ethics Charter of this project, I hereby declare my consent to participate in this research project.