Survey of ALS and Occupations

Please specify your current age by choosing one of the following groups.

• 10-20 years
• 21-30 years
• 31-40 years
• 41-50 years
• 51-60 years
• 61-70 years
• 71-80 years
• 81-90 years
• > 91 years
• 0-9 years

Approximately how long ago were you diagnosed with ALS?

• 1 year ago
• 2 years ago
• 3 years ago
• 4 years ago
• 5 years ago
• 6 years ago
• 7 years ago
• 8 years ago
• 9 years ago
• > than 10 years ago

Was your ALS diagnosis classified as Familial or Sporadic?

• Familial (FALS)
• Sporadic (SALS)

Place a check next to any/all of the following industries in which you worked. Please answer relative to past and/or present jobs held.

Please select all that apply.

• Electrical/Electrician/Electromagnetic Industry
• Chemical/Chemist
• Hairdresser/Nail Technician
• Painter (automobile, house, artist, craftsman, etc.)
• Military (any branch of service)
• Farming/Agricultural
• Dry Cleaning/Other Cleaning Industry (commercial or residential cleaners)
• Athletics (elementary, high school, college, professional, semi-professional or amateur; all contact sports of any kind)
• Leather/Shoe Manufacturing Industry
• Petroleum Industry (Diesel, Jet Fuel or Automotive type fuels)
• Medical Radiology/Other Radiology
• Pest Control
• Metal Fabrication/Welding

What is your gender?

• Female
• Male

Do you have Mercury fillings in your teeth?

• Yes
• No