Own Your Path Screening Survey

Please complete this survey to see if you meet the requirements for the Own Your Path program. By completing this survey, you are giving consent for NHF or our program partner NexJ to contact you regarding next steps.
1.How old are you?
2.What gender do you identify with the most?
3.How did you hear about this program?
4.Which type of bleeding disorder have you been diagnosed with?
5.What was the approximate date of your diagnosis?
6.Is your Hemophilia considered:
7.Where do you currently live?
8.Which state do you live in (if you are in the U.S.A)? Which country do you live in if you are outside of the U.S.A.?
9.Which HTC do you use?
10.If you don't go to an HTC, which provider do you see to manage your bleeding disorder?
11.Which best describes your prescribed treatment schedule?
12.What type of treatment product do you currently use?
13.In the last 3 months, how often have you followed your prophy treatment plan as prescribed by your health care provider (treated with the correct dose and on the prescribed day)?
14.Your First and Last Name
15.Your Phone Number
16.Your email address
17.Please confirm your email address