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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?
Younger than 18
18-23
24-29
30-39
40-49
50-59
60-69
70-79
80-89
2.
What gender do you identify with the most?
Female
Male
Trans male (female to male)
Trans female (male to female)
Non-binary
Intersex
Prefer not to answer
Prefer to Describe
3.
How did you hear about this program?
HTC
Chapter
Social Media
Friend/Family Member
Email
Webinar
Podcast
4.
Which type of bleeding disorder have you been diagnosed with?
Hemophilia A
Hemophilia B
Other bleeding disorder
I do not have a bleeding disorder
5.
What was the approximate date of your diagnosis?
6.
Is your Hemophilia considered:
Mild
Moderate
Severe
7.
Where do you currently live?
United States or US Territory
Other
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?
Prophylaxis (aka “do prophy” or treat on a regular basis to prevent bleeding episodes and expect to do so for the foreseeable future)
Prophylaxis (aka “do prophy” or treat on a regular basis to prevent bleeding episodes and will do so for an extended period (sports season, procedure, etc.) but not forever
On-demand (only treat when you have a bleed)
I am not sure
12.
What type of treatment product do you currently use?
Standard half-life factor products (e.g., Advate, Benefix, etc.)
Extended half-life factor products (e.g., Eloctate, Alprolix, etc.)
Non-Factor treatment product (e.g., Hemlibra)
Clinical trial study drug
No product, received Gene Therapy from a clinical trial
I am not sure
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)?
less than 25%
26%-50%
51%-75%
76%-100%
14.
Your First and Last Name
15.
Your Phone Number
16.
Your email address
17.
Please confirm your email address