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About Yourself
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The following optional information will help us to serve you better. If you prefer to skip this section, please scroll to the bottom and click “Submit.” Thank you.
Diagnosed with FTD
1. What is your gender?
2. Do you have children under 18 living at home?
3. What is your diagnosis?
4. What is the name of your primary caregiver?
5. What is the email of your primary caregiver or care partner?
6. What is your relationship to your primary caregiver or care partner?
7. Are you currently in touch with others diagnosed with FTD for support?
8. Would you like to be contacted by AFTD if other people diagnosed with FTD in your area are looking for support?
For more details contact AFTD’s Helpline by phone or email.
Healthcare Professional Information
A. What is your organization or affiliation?
If you are not affiliated with another organization, please enter Private Practictioner.
B. What is your job title?
C. What is your academic background or training?
C. If other:
D. Which of the below best describes your role as a healthcare provider? (Choose all that apply)
E. What are your main interests or needs related to FTD?
Please tell us about yourself.
Question 1 (optional): What is your gender?
Question 2 (optional): Do you have children under 18 living at home?
Question 3 (optional): What best describes your role as a caregiver or care partner?
Question 4 (optional): What year did your loved one pass away?
Question 5 (optional): Are you currently in a support group?
Question 6 (optional): Would you like to be contacted by AFTD if other caregivers in your area are looking for support?
For more details contact AFTD's Helpline by phone or email.
Please tell us more about your experience with FTD.
Question A (optional): What is your loved-one's diagnosis?
Question B (optional): What is the name of the person diagnosed?
First Last
Question C (optional): What is your relationship to the person diagnosed?
Question C (optional): If other, I am his or her...
Question D (optional): Where does the person with FTD currently live?
Question D (optional): If other, please describe:
Question E (optional): What is the person's birthdate?
Date Format: MM slash DD slash YYYY
Question F (optional): What was the person's age at diagnosis?
Please enter a number less than or equal to 120.
Question G (optional): Was your loved-one employed at the time of diagnosis?
Question H: What is this person's gender?
Question I: Does he/she have children under 18 living home?

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About Yourself

Diagnosed with FTD

Healthcare Professional Information

Please tell us about yourself.

Please tell us more about your experience with FTD.