| Note: All fields of this form are mandatory |
| Name |
|
| Sex |
Male
Female |
| Age |
|
| Qualification: | |
| E-mail address: | |
| Phone no: | |
| Address For communication: | |
| Country: | |
| Doyou have any muscular disorder: | YesNo |
| Zip Code | |
| Please note, if the patients find themselves unable to register online on their own, their family
members/guardians/relatives or friends may register on their behalf with their consent. |
| Type of neuro muscular disease |
|
If you have ataxia,select type
|
|
| If you would like to report more information in brief like patient?s symptoms/onset of disease/present condition etc, enter in the given box below |
|
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