Mitochondrial and Gastrointestinal Diseases Assessment



Genetic InformationWhat mitochondrial disease diagnosis is present? (Specify)Is there a known genetic diagnosis?Yes NoIs this a nuclear or mitochondrial DNA mutation?Nuclear MitochondrialNuclear Mutation (Specify):Mitochondrial DNA mutation (Specify):Demographic InformationHow is person related to the person with mitochondrial disease?The person with mitochondrial diseaseMotherFatherGuardian (not a relative) Grandmother GrandfatherSister Brother Spouse Other, Specify Weight(Specify)Height (Specify)Mother's Height (Specify)Father's Height (Specify)Have you/ your child had any of the following problems?VomitingGERD, heartburn, mid-line chest pain, esophageal burningOral regurgitation BurpingDifficulty or pain with swallowing Feeding difficultiesAbdominal painEarly satiety (Early fullness) Abdominal bloating or distensionProblems with bowel movements (diarrhea, constipation, straining, pain with bowel movements, blood in the stool)Poor appetite affecting growth Cyclic vomitingSpecific questions about how you/your child eats:How does you/your child eat? Eats by himself (regular diet)Infant formula (not specialized) Infant formula (specialized)Liquid diet (non-infant)Gastrostomy (G-tube)Jejunostomy (J-tube)Gastrojejunostomy (G-J tube)Nasogastric tube (NG tube)They do not take any food by mouth or feeding tube TPN (total parenteral nutrition)What kind of infant formula? (Specify)Why do you/they eat that way? (Specify)What liquid diet do you/they use? (Specify)Are you/your child currently on a restricted diet? YesNoWhat type of specialized diet do you/they eat?Ketogenic dietCeliac diet /gluten free VegetarianVegan OrganicFood allergen avoidance (shellfish, eggs, nuts, etc.)Lactose free Sucrose free Fructose Low fatLow carbohydrate Low proteinHigh fatHigh carbohydrateHigh proteinLow Fermentable Oligo-Di-Monosaccharides and Polyols OtherSpecialized diet other (Specify)Why are you/they on a specialized diet? (Specify)Has your/their symptoms changed since the diet started? (Specify)Have you/your child ever been on a restricted diet in the past?YesNoWhat type of specialized diet were you/they on?Ketogenic DietCeliac Diet/Gluten Free VegetarianVegan OrganicFood Allergen avoidance (shellfish, eggs, nuts, etc)Lactose Free Sucrose Free Fructose Free Low FatLow Carbohydrate Low ProteinHigh Fat High Carb High ProteinLow Fermentable Oligo-Di-Monosaccharides and PolyolsOtherOtherWhy did you/they stop?Did the diet affect symptoms?What other dietary restrictions does you/your child have?VomitingDoes you/your child have vomiting currently or in thePresentpast?PastWhat was your/your child's age when the problemsOn the day of birthbegan?Less than 2 mo (not on day of birth)2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than 18 y I don’t knowFor the current vomiting episodes, were any of theRight after birthfollowing triggers present at the time symptoms began?FeverUpper respiratory infection SurgeryDiarrheaProlonged fasting (i.e., not eating well) After starting a medicineDuring exercise After a seizure After traumaI don’t know OtherPresent trigger other.Are the symptoms pretty consistent from day to day?Yes NoMultiple times a dayHow often does you/your child vomit?Once a dayAt least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherVomiting Frequency OtherWhen you/your child has vomiting is it only a singleSingle episodeepisode or do you/they usually vomit repeatedly?Vomits more than onceVomits repeatedly until there is nothing leftDoes the vomiting happen during a specific time ofMorning (wake up until 12pm) the day?Afternoon (12pm - 5pm)Evening (5pm - Bed) Overnight (wakes from sleep) All times of dayAre there particular triggers for vomiting episodes?Yes NoI don’t knowWhat triggers vomiting episodes?Do any of the following occur frequently beforeFasting more than 12 hoursvomiting starts?Viral illness/FeverTaking medicine Right after feeding SeizureHeadache/Migraine/Light sensitivity ExerciseStressDoes you/your child ever have bright green or yellowYesvomiting?NoI don’t knowHow often has green or yellow vomiting occurred?Only onceLess than half of vomiting episodes Most vomiting episodesAll vomiting episodesDoes you/your child ever vomit blood?Yes NoI don’t knowWhat color is the blood?Bright redDark red Brown BlackI don’t knowDo you ever see blood clots in what you/they vomit?Yes NoI don’t knowDoes you/your child have black stool? Note: If theyYesanswer yes, confirm that stool was really black andNonot dark brown or dark green.I don’t knowDoes you/your child have abdominal pain beforeYesvomiting?NoI don’t knowAbdominal painWhich symptom is most severe with vomiting episodes?Nausea BothPlease provide additional details about current vomiting symptoms.Past VomitingHow old were you/your child when you first startedOn the day of birthhaving issues with vomiting?Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo mo to 3 y 4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than18 y I don’t knowHow old were you/your child when the vomiting stopped?On the day of birthLess than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than18 y I don’t knowWhat stopped the vomiting?In the past, were the symptoms consistent from day toYesDay?NoDuring that period, how often did you/they vomit?Multiple times a day Once a dayAt least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherPast Vomiting frequency, Other (Specify):In the past, when you/your child had vomiting, was itSingle episodeonly a single episode or did you/they usually vomitVomited more than oncerepeatedly?Vomited repeatedly until there was nothing leftDid the vomiting happen during a specific time of theMorning (wake up until 12pm) day?Afternoon (12pm - 5pm)Evening (5pm - Bed) Overnight (wakes from sleep) All times of dayIn the past, were there any particular triggers forYesvomiting episodes?NoI don't knowIn the past, what had triggered vomiting episodes?Fasting more than 12 hoursDid any of the following occur frequently before thevomiting started?Viral illness/FeverTaking medicine Right after feeding SeizureHeadache/Migraine/ Light sensitivity ExerciseStressDid you/your child ever have bright green or yellowYesvomiting?NoI don't knowHow often did the green or yellow vomiting occur?Only onceLess than half of vomiting episodes Most vomiting episodesAll vomiting episodesDid you/your child ever vomit blood?Yes NoI don't knowWhat color was the blood?Bright redDark red Brown BlackI don't knowDid you ever see blood clots in what you/they vomited?Yes NoI dont knowDid you/your child ever have black stools?Yes NoI don't knowDid you/your child have abdominal pain beforeYesvomiting?NoI don't knowWhich symptom was most severe with past vomiting episodes?Abdominal PainNausea BothIn past episodes of vomiting, was any of theRight after birthfollowing triggers present at the time symptoms began?FeverUpper respiratory infection SurgeryDiarrheaProlonged fasting (i.e., not eating well) After starting a medicineDuring exercise After a seizure After traumaI dont know OtherPast Triggers Other, (Specify):Please provide additional details about your/their past vomiting symptoms.Cyclic VomitingHave you/your child ever been diagnosed with cyclicYesvomiting?NoI don't knowDo you/your child have a history of migraines?Yes NoDo you have a family history of migraines?Yes NoHave you/they ever experienced vision changes orVision Changesauras?AurasBoth NeitherGERD, Heartburn, Mid-line Chest Pain, Esophageal BurningHas you/your child had GERD, heartburn, mid-linePresentchest pain, esophageal burning in the past orPast currently?For the current GERD, heartburn, mid-line chest pain,On the day of birthesophageal burning episodes, what was your/their ageLess than 2 mo (not on day of birth) when the problems began?2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than 18 y I don’t knowAre the symptoms pretty consistent from day to day?Yes NoHow often do you/they have GERD, heartburn, mid-lineDailychest pain, esophageal burning?At least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don’t knowDoes GERD, heartburn, mid-line chest pain, esophagealYes burning disrupt activity?NoDoes GERD, heartburn, mid-line chest pain, esophagealYes burning wake you/your child from sleep?NoPlease provide additional details about your/their GERD, heartburn, mid-line chest pain, esophageal burning symptoms.Past GERD, Heartburn, Mid-line Chest Pain, Esophageal BurningFor past GERD, heartburn, mid-line chest pain, esophagealOn the day of birthburning episodes, what was your/your child's ageLess than 2 mo (not on day of birth) when the problems began?2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than 18 y I don’t knowHow old were you/your child when the symptomsOn the day of birthstopped?Less than 2 mo (not on day of birth)2 mo to 5 mo6mo to 12 mo 13 mo to 18 mo 19 mo to 3 y4 y to 6 y7 y to 13 y14 to 18 yGreater than 18 y I don’t knowWhat stopped the GERD, heartburn, mid-line chest pain, and esophageal burning?In the past, were the symptoms pretty consistent fromYesday to day?NoHow often did you/they have GERD, heartburn, mid-lineDailychest pain, esophageal burning?At least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don’t knowDid past GERD, heartburn, mid-line chest pain, esophagealYesburning disrupt activity?NoDid past GERD, heartburn, mid-line chest pain, esophagealYesburning wake you/your child from sleep?NoPlease provide additional details about your/their past GERD, heartburn, mid-line chest pain, esophageal burning symptoms.Oral RegurgitationDo you/your child have oral regurgitation or havePresentthey had oral regurgitation in the past?PastFor the current oral regurgitation episodes, what wasOn the day of birthyour/their age when the problems began?Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than 18 y I don’t knowAre the symptoms pretty consistent from day to day?Yes NoHow often does the oral regurgitation occur?DailyAt least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don’t knowOral Regurgitation Other (Specify)Is the oral regurgitation before, during, or afterBeforemeals?DuringAfter VariablePlease provide additional details about your/their oral regurgitation symptoms.Past Oral RegurgitationIn past oral regurgitation episodes, what wasOn the day of birthyour/your child's age when the problems began?Less than 2 mo old (not on day of birth)2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y14 y to 18 y Greater than 18 y I don’t knowHow old were you/your child when the symptomsOn the day of birthstopped?Less than 2 mo (not on day of birth)2 mo to 5 mo6 mo to 12 mo13 mo to 18 mo19 mo to 3 y 4 y to 6 y7 y to 13 y14 y to 18 yGreater than 18 y I don’t knowWhat stopped the oral regurgitation?Were the symptoms pretty consistent from day to day?Yes NoIn the past, how often did the oral regurgitation occur?DailyAt least once a week, but not dailyOne to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don’t knowPast Oral Regurgitation Other (Specify)In the past, was the oral regurgitation before,Beforeduring, or after meals?DuringAfter VariablePlease provide additional details about your/their past oral regurgitation symptoms.BurpingDo you/your child have burping or have you/they hadPresent burping in the past?PastFor the current burping problems, what was your/your child’s ageOn the day of birthwhen the problems began?Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y14 y to 18 yGreater than 18 y I don’t knowIs the burping pretty consistent from day to day?Yes NoDoes the burping occur with reflux or abdominalRefluxdistension?Abdominal distensionBothDoes the burping occur with any specific drinks orYesfood?NoWhat food or drink?Please provide additional details about your/their burping symptomsPast BurpingFor the past burping problems, what was your/your child’s ageOn the day of birth when the problems began? Less than 2 mo (not on day of birth) 2 mo to 5 mo6 mo to 12 mo13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than 18 y I don’t knowWhat was your/their age when the burping problem stopped?On the day of birthLess than 2 m (not on day of birth)2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than 18 y I don’t knowWhat stopped the burping? (Specify:)Was the burping pretty consistent from day to day?Yes NoDid the burping occur with reflux or abdominalRefluxdistension?Abdominal distensionBothDid the burping occur with any specific drinks orYesfood?NoWhat food or drink? (Specify:)Please provide additional details about your/their past burping symptoms (Specify:)Difficulty/ Pain with SwallowingDo you/your child have difficulty or pain with swallowing?DifficultyPainBothWhat was your/your child’s age when swallowingOn the day of birth problems began?Less than 2 mo (not on day of birth)2 to 5 mo 6 to 12 mo13 to 18 mo19 mo to 3 y4 to 6 y7 to 13 y14 to 18 yGreater than 18 yI don’t knowAre the swallowing problems occurring with liquids orSolids onlysolids?Liquids and solidsLiquids only I don’t knowHow often do problems with swallowing occur?DailyAt least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don’t knowHas the difficulty in swallowing changed over time? Yes NoPlease provide additional details about your/their swallowing problems.How often does pain with swallowing occur?DailyAt least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don't knowDoes pain with swallowing disrupt activity or wakeNochild from sleep?Pain wakes child from sleep Pain disrupts activityPain wakes child and disrupts activity I don't knowPlease add comments about pain with swallowingDo you/your child feel food gets stuck in your/theirYesesophagus?NoI don' knowWhere do you feel things get stuck?Back of the throat NeckUpper chest Lower chestHave you/your child ever had food or a pill removedYesfrom the esophagus?NoHow many times?Have you/your child ever been diagnosed with any ofAchalasiathe following:Eosinophilic EsophagitisEsophageal strictureFeeding DifficultiesCan you tell me about your/your child’s feeding difficulties?Abdominal PainWhat was your/your child’s age when abdominal pain began?On the day of birthLess than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo19 mo to 3 y4y to 6 y7 y to 13 y14 y to 18 yGreater than 18 yI don’t knowHave you/your child experienced abdominal pain in thePresent past or currently?PastWhat makes you think they have abdominal pain?The child tells me Holds bellyHolds belly and cries or looks uncomfortable Cries without another obvious causeCries all the time Cries with meals Wakes up from sleep IrritabilityOtherI don't knowPlease provide additional details about your/your child’s abdominal pain.Where is the abdominal pain located? Choose all thatUpper abdomen midline (between umbilicus and apply.bottom of ribs)Upper abdomen on the right Upper abdomen on the left Entire upper abdomenNear the belly buttonRight lower quadrant (below umbilicus) Left lower quadrant Lower abdomen midline Entire lower abdomen Entire abdomen Variable locationsI don't knowHow often does abdominal pain occur?DailyAt least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don't knowAbdominal Pain Other (Specify)How long does the abdominal pain last when it occurs?Less than a minuteOne minute to 30 minutes 31 minutes to many hours All dayDay and nightUntil you/the child falls asleep Until you/the child vomits Until you/the child eatsUntil you/the child has a bowel movement Until you/the child urinatesUntil you/the child passes gas VariableNone of the above I don't knowPlease provide additional comments about the duration of abdominal painFasting more than 12 hoursDo any of the following occur frequently beforeabdominal pain starts?Viral illness/FeverTaking medicine Right after feeding SeizureHeadache/Migraine/Light sensitivity ExerciseStress Depression AnxietyOther Psychological Issues Particular FoodsOtherPlease provide additional details about abdominal pain triggers.Does abdominal pain disrupt activity?Yes NoI don't knowDoes abdominal pain wake you/your child from sleep?Yes NoI don't knowIs there anything specific that makes the pain better?Is there anything specific that makes the pain worse?Please provide additional details about present abdominal painPast Abdominal PainWhat was your/your child’s age when past abdominal pain began?On the day of birthLess than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y old4 y to 6 y old7 y to 13 y old14 y to 18 y oldGreater than 18 y old I don’t knowWhat was your/your child’s age when the abdominalOn the day of birthpain stopped? Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y4 y to 6 y 7y to 13 y 14 y to 18 y oldGreater than 18 y I don’t knowWhat stopped the abdominal pain?The child told meWhat made you think they had abdominal pain?Held bellyHeld belly and cried or looked uncomfortable Cried without another obvious causeCried all the time Cried with meals Woke up from sleep IrritabilityOtherI don't knowProvide additional details if desired about what made you think they had abdominal pain.Where was the past abdominal pain located? Choose allUpper abdomen midline (between umbilicus and that apply.bottom of ribs)Right upper abdomenLeft upper abdomen Entire upper abdomenNear the belly buttonRight lower quadrant (below umbilicus) Left lower quadrant Lower abdomen midline Entire lower abdomen Entire abdomen Variable locationsI don't knowHow often did past abdominal pain occur?DailyAt least once a week, but not daily One to 4 times per monthLess than once a month, more than once a year About once a yearOnly once OtherI don't knowOtherHow long did the past abdominal pain last when it occurred?Less than a minuteOne minute to 30 minutes 31 minutes to many hours All dayDay and nightUntil you/the child fell asleep Until you/the child vomited Until you/the child ateUntil you/the child had a bowel movement Until you/the child urinatedUntil you/the child passed gas VariableNone of the above I don't knowPlease provide additional comments about the duration of past abdominal painFasting more than 12 hoursDid any of the following triggers occur frequently beforebefore abdominal pain started?Viral illness/FeverTaking medicine Right after feeding SeizureHeadache/Migraine/Light sensitivity ExerciseStress Depression AnxietyOther psychological Issues Particular FoodsOtherPlease provide additional details about past abdominal pain triggers.Did abdominal pain disrupt activity?Yes NoI don't knowDid abdominal pain wake you/ your child from sleep?Yes NoI don't knowIs there anything specific that made the pain better?Is there anything specific that made the pain worse?Please provide additional details about past abdominal pain.Early SatietyCan you tell me about your early fullness?Abdominal Bloating and DistensionDo you/your child have bloating or abdominalPresentdistension or have they had it in the past?PastWhat was your/your child’s age when the abdominal bloating/On the day of birthdistension problems began?Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14 y to 18 y Greater than 18 y I don’t knowIs the bloating or abdominal distension worse at anyMorning (wake up until 12pm) particular time of day?Afternoon (12pm - 5pm)Evening (5pm - Bed) Overnight (wakes from sleep) All times of the dayI don't knowAirDo you think the belly is distended with air or withstool?StoolBothI don't knowAre you/your child an air swallower?Yes NoI don't knowPlease provide additional details about abdominal bloating and distensionPast Abdominal Bloating and DistensionWhat was your/your child’s age when the past abdominal bloating/On the day of birthdistension problems began?Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14 yto 18 y Greater than 18 y I dont knowWhat was your/your child’s age when the past abdominalOn the day of birthbloating/distension stopped?Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13mo to 18 mo 19 mo to 3 y 4 y to 6 y7 y to 13 y14 y to 18 yGreater than 18 y I don't knowWhat stopped the past abdominal bloating/distension?Was the past bloating or abdominal distension worse at anyMorning (wake up until 12pm) particular time of day?Afternoon (12pm - 5pm)Evening (5pm - Bed) Overnight (wakes from sleep) All times of the dayI don't knowDid you think the belly was distended with air or withAirstool?StoolBothI don't knowPlease provide additional details about past abdominal bloating and distensionGeneral Stool Questions:How often do they have bowel movements?More than once a day Once a dayEvery other dayA few times a week Once a weekLess than one a week Only after a suppositoryOnly after an enema/irrigation/suppository Requires disimpaction with a fingerUses a cecostomy to induce bowel movements Requires Go lightly by mouth or tubeOtherI don't knowStool Frequency Other (Specify):What is the consistency of bowel movements? (BristolWaterystool scale classification)MushySoft Formed HardHard and large Variable GreasyType 1: Separate hard lumps, like nuts (hard to pass)Type 2: Sausage-shaped, but lumpyType 3: Like a sausage but with cracks on its surfaceType 4: Like a sausage or snake, smooth and soft Type 5: Soft blobs with clear cut edges (passed easily)Type 6: Fluffy pieces with ragged edges, a mushy stoolType 7: Watery, no solid pieces. Entirely liquid I don't knowDo you/your child use a toilet or a diaper?Toilet DiaperBowel Movement ProblemsWhat was your/your child's age when the bowel movementOn the day of birthproblems began?Less than 2 mo (not on day of birth) 2 mo to 5 mo 6 mo to 12 mo 13 mo to 18 mo 19 mo to 3 y 4 y to 6 y 7 y to 13 y 14y to 18 y Greater than 18 y I don’t knowDo you/they have to strain to pass bowel movements?Yes NoI don't knowDo you/your child ever have blood in the stool?Yes NoI don't knowWhat color is the blood in the stool?Bright redDark red (maroon) BlackI don't knowWhat is the largest amount of blood you have seen inSmall streaks (i.e., not three dimensional) the stool?Small clumps of clotsBig clots of blood (larger than a dime)Do you/your child use medicine or otherYestreatment to help with bowel movements?NoWhat treatment do you/your child use to help withGlycolax, PEG, Polyethylene Glycol bowel movements?Mineral oilKondrumelMilk of Magnesia Senakot or other SennaColaceDulcolox suppositoryPrune juice, apple juice, Kayro syrup Fleets enemaSaline enemaMilk and molasses enema ImodiumLomotil Peptobismol OtherDefecation Treatment Other:Have they used any other treatments in the past to help with bowel movements?Did these treatments help or worsen the bowel movement problem?Please provide additional details about bowel movement problems.Poor appetite affecting growthCan you tell me more about the poor appetite affecting growth?General Medication/ Treatment/Surgery QuestionsWhat other medicines are you/your child taking now?Proton pump inhibitor: Prilosec (omeprazole),Nexium, Prevacid (lansoprazole), Protonix (pantoprazole) or Aciphex (rabeprazole)H-2 receptor antagonist: Pepcid (famotidine), Zantac (ranitidine), Tagemet (cimetidine) CarafateOndansetron (Zofran)Tricyclic antidepressant: Amitriptyline, desipramine, imipramine, nortiptylineSSRI: Citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft)Erythromycin Cisapride (Propulsid)Domperidone (Motilium) Reglan (metaclopramide) Tegaserod (Zelnorm, Zelmac) Linaclotide (Linzess)CoQ10 (Ubiquinol, Ubiquinone) Riboflavin (vitamin B2)L-Creatine L-Arginine L-CarnitineB vitamins (other) Vitamin E Vitamin CAlpha lipoic acid Folinic acidCarbamazepine (Tegretol, Carbatrol) Ethosuximide (Zarontin)Felbatol (Felbamate) Tiagabine (Gabatril) Levetircetam (Keppra) Lamotrigine (Lamictal) Pregabalin (Lyrica) Phenytoin (Dilantin) Topamax (Topiramate) Oxycarbazine (Trileptal) Gabapentin (Neurontin)Pancreatic enzyme supplements (Creon) Levbid/Levsin/BentylAntibiotics OtherWhat other medicines do you/your child take?Have you/ your child taken any medications in the past that you feel helped any of your/your child's GI problems?Have you/your child taken any medications in the past that you feel have worsened your/your child's GI problems?Have you/your child tried any "alternative medicineYesapproaches" to help with any of the problems weNo discussed?What types of alternative medicine have you/yourMeditationchild tried?YogaAcupuncture CrystalFaith healer Prayer Massage ExerciseHerbal supplements or medicines Homoepathic medicine Chiropractic careColon cleansing Aromatherapy AntioxidantsSupplemental vitamins (not prescribed) MarijuanaGingerOver the counter medicine Items bought over the internet OtherWhat other alternative medicine have you/your child tried?Did any of these alternative medicine treatments help your/their GI issues?Did any of these alternative medicine treatments worsen your/your child’s GI problems?Have you/your child ever had surgery?Yes NoG-tubeWhat type of surgery or procedures have you/they had?J-tubeG J - tube (e.g., for venting and feeding)Colostomy Ileostomy JejunostomyCecostomy (to treat refractory constipation) Hirschsprung (Swenson, Duhamel, Soave) Fundoplication (Nissen, Toupet)Bowel resection Bowel dilation Botox injection Upper endoscopy ColonoscopyEsophageal manometry Antroduodenal manometry Colon manometry Anorectal manometry Gastric emptying studies Esophageal pH monitoringEsophageal impedance monitoring Bladder surgeryBrain surgery Heart surgery Lung surgeryAirway surgery (tracheostomy, laryngomalacia) Kidney surgeryLiver surgery Spleen surgeryOrthopedic surgery (bone or joint) Organ transplantMuscle BiopsyProvide additional details about the type of surgery here.GI and social issuesHow much do the symptoms we discussed affect1your/ life? (1 being not at all, 10 being severe2interruption)345678910If there was a clinical trial regarding GIYesissues, would you/they participate in it?NoI don’t knowHow long did you/they have GI symptoms before you were diagnosed with mitochondrial disease?How many GI doctors have you/they seen?Were these GI symptoms what led to your/ mitochondrial disease diagnosis?Were your/ GI symptoms recognized as significant before diagnosis of mitochondrial disease?problems for fear of not being believed about theseNosymptoms?I don't knowHave you ever been referred to a psychiatricYesprofessional regarding your/your child's GI symptoms?NoI don't knowHave you ever been concerned about a Munchausen byYes proxy accusation?NoI don't knowHave you ever had a confrontation with a health careYesprofessional about Munchausen by proxy syndrome?NoI don't knowWhat setting was this in?EROutpatient Clinic Hospital stay OtherMunchausen Setting OtherIs there anything else you want to tell us? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download