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Last Name 

Male Female

 Diagnosis

Date of Diagnosis

Neurologist or Clinic who made diagnosis

Select One PLS confirmed PLS suspected ALS confirmed ALS suspected Undiagnosed at this time

Has your diagnosis been confirmed by a 2nd neurologist/clinic?     Yes No

Were you misdiagnosed prior to PLS dx?     Yes No

How long did it take you to get a diagnosis?   

MM/YYYY        Area of Symptom Onset                 Comments

Select One unexplained falling foot drag peculiar gait arm/hand weakness, clumsiness speech, hoarse, slow or slurred extreme fatigue extreme spasticity swallowing, choking, breathing difficulties unable to walk No other symptoms left right both N/A

MM /YYYY       Area of Symptom                             Comments

Select One unexplained falling foot drag Peculiar gait Arm/hand weakness, clumsiness Speech, hoarse, slow or slurred Extreme fatigue Extreme Spasticity Swallowing, choking, breathing difficulties Unable to walk No other symptoms Left Right Both N/A   

Select One Unexplained falling Foot drag Peculiar gait Arm/hand weakness, clumsiness Speech, hoarse, slow or slurred Extreme fatigue Extreme Spasticity Swallowing, choking, breathing difficulties Unable to walk No other symptoms Left Right Both N/A

Select One Unexplained falling Foot drag Peculiar gait Arm/hand weakness, clumsiness Speech, hoarse, slow or slurred Extreme fatigue Extreme Spasticity Swallowing, choking, breathing difficulties Unable to walk No other symptoms Left Right Both N/A

Select One Unexplained falling Foot drag Peculiar gait Arm/hand weakness, clumsiness Speech, hoarse, slow or slurred Extreme fatigue Extreme Spasticity Swallowing, choking, breathing difficulties Unable to walk No other symptoms Left Right Both N/A

Select One Unexplained falling Foot drag Peculiar gait Arm/hand weakness, clumsiness Speech, hoarse, slow or slurred Extreme fatigue Extreme Spasticity Swallowing, choking, breathing difficulties Unable to walk No other symptoms Left Right Both N/A

Select One Unexplained falling Foot drag Peculiar gait Arm/hand weakness, clumsiness Speech, hoarse, slow or slurred Extreme fatigue Extreme Spasticity Swallowing, choking, breathing difficulties Unable to walk No other symptoms Left Right Both N/A

MM /YYYY       Spasms, Fasciculations,  Startle Reflex,  Uncontrollable lauging or crying,  etc.

Aids or treatments             Medications, Supplements, Canes,
Year started              AFO's, Baclofen Pump, Botox Injections, etc.

Yes No

Yes No

Yes No

Yes No