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- Lucinda Morgan
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1 PEOPLE WITH MITO Kerry 50 Lismore, Kerry suffers with peripheral neuropathy. She has three children. One Bodenham child has been diagnosed with Complex 4 Deficiency, one child is autistic and suffers with heart defects and one child has gastrointestinal issues. Susan Fedoryschyn John Goodwin Craig Lee Lisa Moult Melissa Targett Tara Collyer Darren Hughes Julie Maguire Kerry.bodenham@bigpond.com Sydney, Diagnosed with mitochondrial myopathy five years ago. suefed7@optusnet.com.au 64 Goulburn, Diagnosed with LHON in Severe loss of central vision with peripheral vision not affected. Also suffers from fatigue, severe migraines and sensitivity to light and sound. LHON has also affected John s mother, uncle and brother. 53 Albury, Diagnosed with mitochondrial myopathy ten years ago. Suffers with decreased energy, especially in the legs and feet. Also suffers with balance issues. 49 Pyrmont, Mito patient diagnosed with atypical KSS. Symptoms started in 2004, diagnosed after six years in Looking to connect with other patients and carers. 27 Tamworth, Diagnosed with POLG mutation at 25. Suffers with vertigo, ataxia and frequent falls, among other symptoms. 44 Logan City, Tara was diagnosed 19 years ago with mitochondrial encephalopathy (possible unknown MELAS phenotype). As a result of her mito she is profoundly deaf, in a wheelchair, TIAs, strokes, migraines, muscle weakness, fatigue, exercise intolerance, dysautonomia, seizures, etc. Teacher for 20 years before retiring for medical reasons. 50 Atherton, Darren was diagnosed with mitochondrial myopathy in Darren has received little information about mito since his diagnosis. He is very happy to be contacted by people in the mito community to share his experiences. 66 Sunshine Coast, Diagnosed four years ago with mitochondrial myopathy. Suffers with fatigue, leg weakness, croaky voice. Has been through three operations to repair eyesight. john.robyn@bigpond.com mito@moults.com mitza_6@hotmail.com collyer3@hotmail.com (SMS only) dazdani@iprimus.com.au jkmag9@bigpond.com If phone unanswered, please leave a message Available during the day on weekends; between 2pm 5pm on weekdays. Happy to be contacted any time, but may take hours for first reply.
2 Annie Midgley 62 Petrie, Diagnosed with mitochondrial cytopathy after many years of looking for a diagnosis. Annie suffers with chronic pain and fatigue; as well as poor vision, diabetes, early stage kidney disease, sleep disorders and difficulty in swallowing. amidgley@internode.on.net Aimee Morton Bec Patterson Patricia Spence Mia Bell Pam Hausler James Crawford Alice Gibson 20 Brisbane, As of Sept 2015 has 20% hearing and relies on lip-reading. Also has damage to the optic nerve. Has issues with speech. Suffers with weak muscles and has days where walking is impossible. Suffers with lack of energy and difficulties in sleeping. Mother and maternal grandfather also diagnosed with mito. 19 Airville, Bec was diagnosed with mitochondrial disease after four years of unexplained severe abdominal pain and fatigue. During this time, she also lost her voice, had shortness of breath and severe chest pain. Her symptoms meant she had to give up her career as a hairdresser. Bec now uses a wheelchair for transport. You can read more about Bec's diagnostic journey here. Bec is happy to share her experience with others affected by mito, and is especially keen to connect with other young people. 81 Patricia was diagnosed in 2008 but symptoms began in the 1960s. Patricia has issues with balance, climbing stairs, swallowing and breathing. aimee.d.m@hotmail.com becpatterson97@hotmail.com fringfordfilly@gmail.com Adelaide, SA Diagnosed in the UK in 2003 with mitochondrial myopathy 3302 A>G Adelaide, SA Diagnosed with MELAS. Dealing with symptoms such as muscle cramps/weakness, migraine headaches and gut and bowel problems. Pam has lost both her mother and daughter to MELAS. pamhausler@gmail.com 50 Franklin, TAS Diagnosed with LHON. Lost central vision at age eight. jagc@bigpond.net.au Flemington, VIC Alice was diagnosed with COX negative deficiency in July She is currently still going through the diagnostic pathway. alicemaygibson@gmail.com SMS only Patricia can be contacted before 6pm Please call before 6pm
3 Tracy 45 New Zealand Diagnosed with MELAS in Suffers with censorial deafness and Pullin wears bilateral hearing aids. Daughter also carries the same genetic mutation. Carers Yasmin Mizrak Patrick Moult Donna Strain Dawn Richards Tony Richards Vicki Hardie Laura Atwell 47 Auburn, Fourteen year old daughter diagnosed with Leigh Syndrome. She suffers with difficulties in swallowing, but is otherwise quite well. 54 Pyrmont, Carer for his wife, Lisa. Happy to share experiences with both carers and patients North-west Teenage son diagnosed with Barth s Syndrome. Brisbane, 69 Gold Coast, Daughter has suspected Mito, based on the marker 3Methylglutaconic acid urea. She has been tested for 13 years and has symptoms of extreme fatigue, confusion, anxiety, intellectual disability, odema in her legs, episodes of mental illness-like behaviour (delusions, hallucinations) and episodes of dementia-like behaviour (but no significant change in the brain MRI). Desperate to get a diagnosis so that she can plan for our daughter s future. 69 Gold Coast, Daughter has suspected Mito, based on the marker 3Methylglutaconic acid urea. She has been tested for 13 years and has symptoms of extreme fatigue, confusion, anxiety, intellectual disability, odema in her legs, episodes of mental illness-like behaviour (delusions, hallucinations) and episodes of dementia-like behaviour (but no significant change in the brain MRI). Desperate to get a diagnosis so that he can plan for our daughter s future. bandtpullin@gmail.com yasmin.mizrak@hotmail.com mito@moults.com donnapepworth@hotmail.com dawn@ssms.com.au dawn@ssms.com.au 67 Adelaide, SA Carer for an adult mito patient who was diagnosed later in life. ronandvicki@live.com.au Melbourne, VIC Young daughter Ivy in the process of being diagnosed with Leigh s Syndrome. Ivy suffers with seizures, hearing loss, and significant developmental delay including no neck control. lauratucker88@gmail.com is best way to contact due to problems with hearing, however phone can be used on weekends. Please call after 3pm If phone unanswered, please leave a message.
4 Don Perth, WA Daughter was diagnosed with MELAS at age 19. She is now 38. Beard Suffers with cognitive loss, hearing loss, muscle weakness, diabetes, gut and bowel issues, fatigue and epilepsy. Don and his wife are longterm carers. Lesley Spence Brian Russell Kris Russell 50 Northern Suburbs, Perth, WA Lost a loved one to Mito Karen Crawley Ashleigh Hill Sean Murray Tracy Taprell Jane Cleary Rural Southland, New Zealand Rural Southland, New Zealand 48 South Sydney, 25 Sydney Northern Beaches, 43 Inner Sydney, 42 City of Logan, 46 Inner Northern Perth, WA Lesley has a son Jason, 23, who has been diagnosed with NARP. He suffers with weak legs and uses a frame or wheelchair to get around. He also suffers with sleep apnoea, heart rhythm irregularities and weight issues. Twelve year old daughter diagnosed with KSS one year ago. Twelve year old daughter diagnosed with KSS one year ago. Teenage daughter diagnosed with MELAS. Suffered her first stroke at age eight. Suffers with dementia, sight and hearing issues, digestive issues. Diagnosed carrier of LHON, which took the eyesight of her brother at 20 and Grandmother. Possible LHON Plus link (strokes in family). Received genetic counseling in 2014 for family planning. See Ashleigh s story here. Family history of MELAS lost his brother in 2006 (aged 45) and mother in 2008 (aged 70). Other family members also affected. Tracy lost her son Dion at three years of age from Leigh's Syndrome, seven years ago. Tracy has been involved with the AMDF and providing support to the mito community for many years, and is comfortable talking about Dion and mitochondrial disease. You can read the Taprells story here. Lost her son at seven months old. See Archer s story here. donbeard52@hotmail.com lesley.66@iinet.net.au deerpark@farmside.co.nz deerpark@farmside.co.nz Available evenings Available evenings Limited availabilities on Tuesdays. ashleigh.hill.work@gmail.com ttaprell@yahoo.com.au jane.cleary@iinet.net.au Tracy can also be contacted via private message on Facebook- she is a member of the AMDF Facebook group.
5 Rene 38 Hobart, Raichert Tasmania Son diagnosed with Leigh Disease at nine months and passed away at 19 months of age (2014). Cognitive impairment, motor delays, severe Lactic acidosis
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Kerry 50 Lismore, Kerry suffers with peripheral neuropathy. She has three children. Bodenham One child has been diagnosed with Complex 4 Deficiency, one child is autistic and suffers with heart defects
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Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
Mercy Metabolic and Bariatric Surgery Program Questionnaire
Mercy Metabolic and Bariatric Surgery Program Questionnaire Interested in bariatric surgery? Complete this form and return to us to be considered for evaluation: Sara Maduka, Mercy Metabolic and Bariatric
Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:
Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?
NC Neuropsychiatry, PA HEALTH QUESTIONNAIRE
NC Neuropsychiatry, PA HEALTH QUESTIONNAIRE Name: DOB: Please give us as much information as you can about your prior medical history. If possible, give dates, medication doses, names and phone numbers
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
Please complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
Northern Ireland Chest Heart & Stroke. What are Chest, Heart and Stroke conditions?
Northern Ireland Chest Heart & Stroke What are Chest, Heart and Stroke conditions? Everyone in Northern Ireland knows someone who has suffered from a chest, heart or stroke condition. 40% of adult deaths
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status: