Beacon Interest — Genetic Conditions

Who is completing this form?

Myself Parent/legal guardian Spouse/partner Other caregiver

Full name

Email address

Mobile phone number

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Best time to reach you

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Date of birth

Derives age for eligibility.

Sex assigned at birth

Female Male Intersex Prefer not to say

Gender identity (optional)

Woman Man Non-binary Prefer to self-describe Prefer not to say

City and state

ZIP / postal code

Primary geo-match signal.

How far would you travel for a study?

Under 10 mi 10–25 mi 25–50 mi 50+ mi Remote/at-home only

Preferred language

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I agree to be contacted about future research opportunities that may fit me.

I agree to be contacted about future research opportunities.

I have read the privacy notice and understand my information is stored securely and I can opt out anytime.

I have read and accept the privacy notice.

Which apply? Choose any.

Other genetic condition (please specify)

Your relationship to the condition

I am affected I am a carrier I am at-risk family (untested) I am a parent of an affected child

Confirmed by genetic testing?

Yes No Test pending

Specific gene or mutation, if known (optional)

Sensitive — optional. See privacy notice.

Age at onset / diagnosis

Family history of this condition?

Yes No

Have you had genetic counseling?

Yes No

[CF] On a CFTR modulator (e.g. Trikafta)?

Yes No Don't know

[Sickle cell] Type

HbSS HbSC HbS-beta thalassemia Other Not sure

[Sickle cell] Pain crises per year

0 1–2 3–5 6+

[Huntington's] Gene status

Gene-positive, no symptoms Symptomatic At-risk, not tested

[Hereditary cancer] Personal cancer history?

Yes No