Survey 1 | About you

Directions

This survey is to be answered by or about a single individual who has been diagnosed or told they have FSH muscular dystrophy. (A parent, guardian, or caregiver can respond on behalf of an affected individual. Please answer the questions as if you are the patient.) Your responses are confidential. Responses are tied to a specific IP address. If you have other family members who also have FSHD, please feel free to forward them the email with the link to this survey.

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* 1. Are you (check all that apply):

An individual living with FSHD

A parent or legal guardian of a child with FSHD

A representative of an adult with FSHD

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* 2. Where is your primary residence?

United States (indicate which state below)

Canada

Central or South America (indicate which country below)

Europe or UK (indicate which country below)

Asia (indicate which country below)

Africa (indicate which country below)

Australia or New Zealand

Other (indicate which country below)

Your country or U.S. state

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* 3. What is your (i.e. the patient’s) age?

Younger than 18

18-29 years

30-39 years

40-49 years

50-59 years

60 or older

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* 4. Do you (i.e. the patient) identify as

Male

Female

Other

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* 5. What is your (i.e. the patient’s) race/ethnicity? Check all that apply and include countries of origin in the text box.

White

Black

Latin American

Asian

Near or Middle Eastern

Native American or Alaskan

Pacific Islander

Other (indicate below)

Ancestral country or countries, or geographic region(s)