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All Medical/Health Professionals:
Please complete this Questionnaire
if you would like Families to know that you diagnose, clinically
treat and/or do research with Fatty Oxidation Disorder Children
and/or Adults. Please return via email (copy and paste the info
below) or print
this questionnaire (PDF*), and mail to the address listed below.
Name: _________________________
Professional Title: _________________________
Address: _________________________
Phone: _______________ Fax: _______________
Email: _________________________
Webpage: _________________________
Specialty: _________________________
I have access to lab facilities to test
for/diagnose FODs:
___ Yes ___ No
I clinically treat (Y or N) ___ children
and/or ___adults with an FOD diagnosis
Specific FODs treated: _________________________
Other Metabolic Disorders treated: ____________________
I conduct research involving FODs: ___
Yes ___ No
Main research area: _________________________
How should contact or Referrals be made?
By the child's/adult's Dr ___ or can
families actually call your main office and talk with you or staff
personnel ___
Thank you!
Deb Lee Gould, Director, FOD Family Support
Group
www.fodsupport.org
deb@fodsupport.org
805 Montrose Drive
Greensboro, NC 27410
336-547-8682
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