Patient Registration

Patient's Name

Mother's Name

Father's Name

Mobile Number

Email ID

Sex(required)

Male

Female

Date of birth

Height

Weight

Steroid (Name, dosage & duration)

Other Medication (Name, dosage and duration)

Walking Capability(required)

Yes

Cardiac Function

Respiratory Function

CPK Value

Type of Muscular Dystrophy (DMD/BMD/LGMD/GNE Myopathy/Others

Exon Mutation Details (Deletion/Duplication/Point/Frameshift/Missense/Nonsense)

Correspondence Address

I am interested to participate in the ICMR Rare Diseases Registry(required)

Yes No Need more information on this

I hereby consent to voluntarily provide this information and agree to be contacted if further details are required.

Kindly scan and mail a copy of the patient’s medical reports to supportus@dartindia.in

Mention the name of the patient in the subject.

We would be requesting you by email or phone to give more information to collect your data to enter in this portal.

Dystrophy Annihilation Research Trust