University of North Carolina Please enable JavaScript in your browser to complete this form.Full name *Phone number *Email address *Are you at least 18 years old? *YesNoAre you willing to share your contact information, including name, email address, and phone number with the study team at the location you requested? *YesNoNote: this information will not be shared with the study Sponsor, Cartesian Therapeutics, Inc.Do you have myasthenia gravis (GMG) (not limited to eye involvement)? *YesNoUnsureWhich MGFA Class is indicative of the status of your disease? *I (Any Ocular Muscle)II (Mild weakness affecting muscles other than ocular muscles; may also have ocular muscle weakness of any severity)III ( Moderate weakness affecting muscles other than ocular muscles; may also have ocular muscle weakness of any severity.)IV (Severe weakness affecting muscles other than ocular muscles; may also have ocular muscle weakness of any severity.)V (Defined as intubation, with or without mechanical ventilation, except when employed during routine postoperative management.)I don’t knowWhich of the following treatments are you taking to manage your MG? *Prednisone / Deltasone / DexamethasoneMestinonImuranCellCeptPrografMethotrexateSandimmune / NeoralCytoxan / NeosarRituxanSolirisIntravenous ImmunoglobulinPlasma ExchangeNeonatal Fc receptor antagonistsOther (specify)I do not take any medications for MGIf your disease is NOT well controlled with your current medications, would you be interested in participating in a clinical trial with a new therapy? *YesNoUnsureN/AHave you received plasma exchange or intravenous immunoglobulin (IVIG) to treat your MG within the last 4 weeks? *YesNoNo, but I plan to within the next 1-2 monthsNo, but I plan to within longer than 2 monthsN/AUnsureHave you tested positive for an antibody that causes Myasthenia Gravis, e.g., -N-acetyl-choline receptor antibody? *YesNoUnsureDo you have a medical history of any conditions that are included in the following areas? *Respiratory disease (i.e. COPD, asthma)Heart disease or StrokeRenal diseaseHepatic diseaseAutoimmune diseases (other than MG)DiabetesCancerChronic Infections (i.e. HIV, hepatitis, etc)AllergiesOther (specify)Have you participated in a clinical trial for the treatment of myasthenia gravis...? *Within the last monthMore than a month agoN/ASubmit
