Patient Registration

To ensure you receive the latest news from the Cure JM Foundation, please complete the following Patient Registry. This information will also help us build a database of Juvenile Dermatomyositis and Juvenile Polymyositis sufferers. This information will be used as part of a demographic survey to determine if there are clusters of children affected by JM in the same geographic area. The information you provide will be used exclusively for research, and will not be shared with any other organization or business not connected with this research.

PLEASE COMPLETE ALL FIELDS Contact Information

First Name:
Last Name:
Street Address:
City:
State/Province:	If you selected "Other" please elaborate here
Zip/Postal Code:	Country:
Telephone:
eMail:
eMail Verification:
Alternate eMail:
Relationship to Patient:

Patient Information
First Name:
Last Name:
	Click here if Patient Address is the same as above.
Street Address:
City:
State/Province:	If you selected "Other" please elaborate here
Zip/Postal Code:	Country:
Telephone:
eMail:

Sex of Patient:
Date of Birth:

Type of Myositis: If "Other" please describe:

Diagnosis Information
Date of Diagnosis:
In Remission?
Length of Time between first symptoms and diagnosis: months
Treating Doctor:
Treating Hospital:
Other Health Issues?
Where (geographically) did symptoms first appear?
City:
State/Province:	If you selected "Other" please elaborate here
Country:

Join the Cure JM Family Support Network The Family Support Network was created to give both JM sufferers and parents of children affected by JM the ability to connect and share experiences, questions and concerns. Would you like to join?

Join Team JM Team JM is seeking members who would like to help us raise public awareness of JM, facilitate fundraising efforts, and spread the word about Cure JM. There's no cost to join Team JM, the only thing we require is a passion and desire to eliminate this disease. Would you like to join?

How did you hear about us? If "Other" please elaborate:

Any comments or questions:
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