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CINRG Online Registration Form

Contact Information
  1. Have you been diagnosed? Yes   No

    If yes, what is your diagnosis?

    If yes, how?
    DNA Testing
    DNA Sequencing
    Deletion Test
    Muscle Biopsy
    Western Blot
    Immunofluorescence
    Other  
    Unsure

  2. Can you walk? Yes   No

    If no, how long have you been in a wheelchair?

  3. Have you ever taken steroids or supplements? Yes   No

    If yes, which ones?

  4. Have you been in a research study before? Yes   No

    If yes, when?

  5. Are you interested in participating in any of our trials? Yes   No

  6. Are you willing to have this information stored by CINRG? Yes   No

  7. Can we contact you in the future? Yes   No


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