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Ruby L. Butler Patient Assistance Program - Home Rehab Survey
Contact Information
Name
First Name
Last Name
Email
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Verify Email
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Phone
City
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State
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Select One
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select one
I have received at least one autoimmune diagnosis.
I am the primary caregiver of someone with any autoimmune illness.
Your age range
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select one
0-7 years
8-14 years
15-20 years
21-35 years
36-54 years
55 or older
List 1-3 tasks, in your home, you have found difficult since receiving an autoimmune diagnosis. (Examples: Taking stairs, reaching top cabinets, standing on tile floors, breathing without congestion, opening doors, putting on clothes, using wheelchair)
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To the best of your ability, list 1-3 changes to your home you believe will make the tasks listed in the previous question easier for you.(Expamles: replace door knobs, lower kitchen cabinets, new flooring, add ramp, clean air ducts, etc.)
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What is your autoimmune diagnosis
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What year did you receive your autoimmune diagnosis? If you have receved multiple diagnoses, please list the year of your first diagnosis.
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Do you feel you will benefit from support with maintaining your physicians' regimens and being a proactive part of your family's healthcare?
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select one
Yes, I could benefit from this kind of support.
No, I am proactive and do not require such support.
Your loved one's age range
*
select one
0-7 years
8-14 years
15-20 years
21-35 years
36-54 years
55 or older
List 1-3 tasks,in the home, that are more difficult for your loved one since receiving an autoimmune diagnosis.(Examples: Taking stairs, reaching top cabinets, standing on tile floors, breathing without congestion, opening doors, putting on clothes)
*
To the best of your ability, list 1-3 changes in the home you believe will make the tasks listed in the previous question easier for your loved one. (Expamles: replace door knobs, lower kitchen cabinets, new flooring, add ramp, clean air ducts, etc.)
*
What is your loved one's autoimmune diagnosis
*
What year did your loved one receive his/her autoimmune diagnosis? For multiple diagnoses, please list the year of your first diagnosis.
*
Do you feel your loved one will benefit from support with maintaining physicians' regimens and being a proactive part of the family's healthcare?
*
select one
Yes, I could benefit from this kind of support.
No, I am proactive and do not require such support.
Please contact me about services Many Infinities provides to families battling autoimmune diseases.
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