JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Disease suggestion
Thank you!
Filling this form will help us to assess whether a particular disease may be suitable for developing an algorithm
Please enter as much detail as possible, our medical team will review the content and augment it with public sources.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Disease Information
These questions will help us understand the disease so please be as detailed and precise as possible
What is the name of the disease?
*
Your answer
Please give a brief description of the disease (If possible include a reference link to a well regarded review article)
Your answer
Please tell us the prevalence of the disease (If possible include a reference link)
Your answer
Please list the most prominent/notable symptoms, signs and test results related to the disease
Your answer
Age of onset - Typically when do the first symptoms appear? (It iss possible to choose more than one option)
Congenital
Infancy
Childhood
Teenager
Adult
Other:
Clear selection
Please explain why the disease is hard to diagnose? (If possible include references)
Your answer
Please describe if there are any treatments available for the disease (If possible include references)
Your answer
Is there any patient advocacy group related to the disease?
Yes
No
Clear selection
If Yes, please share the link to the patient advocacy group/s
Your answer
Next
Page 1 of 2
Clear form
Never submit passwords through Google Forms.
This form was created inside of Mendelian.
Report Abuse
Forms
