Care Package Survey

How did you hear about us? *

Internet Search (please list search terms below) Facebook Page (please list which one below) Friend (please list name below) Other (please list below)

Regarding the above question, if you answered Internet Search, what specifically did you search for? If you answered Facebook page, what is the name of the page? If you answered Friend, please provide their full name. If you answered Other, please be specific. *

What is your diagnosis/diagnoses? *

What date were you diagnosed? *

Name of medical facility you were diagnosed at: *

Name of medical facility you are treated at: *

Name of treating physician: *

Treating physician's specialty, i.e., Endocrinologist, Cardiologist, Neurologist, Infectious Disease, Rheumatologist, Orthopedist, etc.: *

What is your gender? *

Female Male Other

Any favorite TV/movie characters, heroes, characters, superheroes or others? *

What do you like to do in your spare time? Hobbies? *

If you enjoy hobbies that involve an electronic device, i.e., downloading music, playing games, apps and/or electronic books, what type of device do you do this on, i.e., Apple, Nook, Android, XBox, Playstation, etc.? *

What are a few of your favorite animals? *

What are your favorite candies, snacks or treats? Any food allergies or special dietary considerations? *

Do you collect anything? If so, what? *

What treatments are you currently undergoing? *

Do you get infusions or injections? If so, what kind? Are these painful for you? *

When you have pain, what helps to distract you? *

Anything else you would like to tell me about you? *

Would you be interested in paying it forward at some point? If yes, may I send you information regarding ways you can help us continue to send care packages to those newly diagnosed? *

Yes No

Name of Recipient *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Person Filling out this form or certifying that this information is true and accurate (must be 18 or over) *

First

Last

Are you the parent, caregiver, other (please explain if other): *

Email address of person over 18 years of age *

Please check the box below to confirm that you are 18 years or older, that you attest that this care package is being requested for someone with CRMO, and that you authorize Kaila's Komfort to use your testimonial and/or photos on our website, Kaila's Komfort Facebook page, and any promotional materials. We would never share personal information, i.e., name, address, email address. If you have any stipulations on the use of your story/photos, please note them in the Comment box below. *

Yes

Please answer the following questions as best you can and provide any additional information that may help me get to know you more so that I may personalize your care package just for you.