Patient Registration  

The Cure JM Foundation is building 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  
Zip/Postal Code:     Country:
Telephone:  
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  
Zip/Postal Code:   Country: 
Telephone:  
eMail:  
   
Sex of Patient:  
Date of Birth:  (MM/DD/YEAR) 
Date of Diagnosis:  (MM/DD/YEAR) 

Where (geographically) did symptoms first appear?
City:  
State/Province  
Country: