Member Registration Form

1. Member Personal Details

First Name *

Middle Name

Last Name *

Date of Birth *

Age *

Gender *

Blood Group

Mobile Number *

WhatsApp Number

Email

2. Father Details

First Name *

Middle Name

Last Name *

Date of Birth

Age

Blood Group

Mobile Number

WhatsApp Number

Email

3. Mother Details

First Name *

Middle Name

Last Name *

Date of Birth

Age

Blood Group

Mobile Number

WhatsApp Number

Email

4. Address

House / Street Address *

Landmark

Taluka

City *

District *

Pin Code *

State *

5. Clinical Details

MD Type *

Other MD Type (please specify)

Age at Diagnosis *

CPK Level

Ambulation Status

6. Genetic Details

Genetic Test Done *

Genetic Report (PDF max 10MB)

7. Medical Records

Upload scanned copy of the Previous Medical Record File, Prescriptions, Laboratory Reports, Muscle Biopsy Report, and Other Reports. (PDF max 100MB)

8. Family History

Any family member affected? *

First Name

Middle Name

Last Name

Date of Birth

Age

Gender

Relation

9. Physician Details

Physician Name

Contact Number

Hospital Name and Address

10. NGO / Institute Connection

Are you connected with any NGO / Patient Support Organization / Research Institute? *

Name and address of NGO / Patient Support Organization / Research Institute *

11. Treatment Type

Allopathic

Homeopathy

Ayurvedic

Unani

Acupuncture

Magneto Therapy

Naturopathy

Physiotherapy

Not Any

Other

12. Declaration and Consent

I declare that the information provided is true and correct. I voluntarily provide the above information for IMDS registration. I understand that this information may be used for research and publication purposes, and I agree that the team may contact me in the future for further information or studies. *