Initial Screening - SPARK

Name of person completing this form:

Relationship to the child:

Address:

Phone:

Email:

Preferred contact:

Phone

Child's first name:

Child's last name:

Child's age:

Child's birth date:

Does your child have a medical diagnosis of Spinal Muscular Atrophy (SMA)?

Please note, your child must have a medical diagnosis of SMA to enroll in the study.

Yes

Age at diagnosis:

If known, indicate your child's specific SMA type classification:

Type 1

Type 2

Type 3

My child wasn't given an SMA type

Unsure

Is your child currently receiving any services or interventions (e.g., special education, physical therapy, occupational therapy, speech or language therapy, vision therapy)?

Yes

Please list the services your child receives:

Is your child’s first and primary language English?

Yes

Are there any other languages spoken in the home?

Yes

Please list the other languages spoken in the home:

Describe how your child communicates with you. Be sure to mention the different modes they use (e.g., verbal speech, gestures, AAC system (speech generating device, eye gaze etc.), and/or sign-language):

Has your child received one of the following FDA-approved disease-modifying therapies?

Please note, your child must have received at least one of these therapies to enroll in the study.

Zolgensma

Evrysdi

Spinraza

Unsure

Other

Sma therapy other:

At what age did your child receive this FDA-approved disease-modifying therapy?

Did your child present with SMA symptoms at the time of treatment?

Yes

Has your child received any medical intervention that may impact their speech production (e.g., tracheostomy, Bilevel Positive Airway Pressure [BiPAP], Continuous Positive Airway Pressure [CPAP]?

Yes

If yes, please describe:

Do you have any concerns about your child's hearing, or have they been diagnosed with hearing loss?

Yes

If yes, please describe: