ALS Survey
Where do you receive your ALS Care? (Select only one option) Required
 VA
 Community Provider
 Both
Which of the following ALS symptoms do you have and are being treated for? (Select all that apply)
Symptom
I have these Symptom(s)
I have received treatment  
for these Symptom(s)
Muscle Weakness
Muscle Cramps
Twitching
Stiff Muscles
Speech Challenges
Trouble Swallowing
Drooling
Involuntary Emotional 
expressions
Fatigue
Trouble breathing or shortness  
of breath
Insomnia
Constipation
Urinary Difficulty
Stomach pain, Nausea, 
bloating, or fullness
Pain
4 4 

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