Parent/Professional Questionnaire

The Association publishes the Organic Acidemia Association Newsletter, which includes updates, editorials, and letters from and for affected families three times a year for a suggested donation of $25 (within the US) and $35 (outside US). They will provide new parents with back copies of the newsletter.We are creating a database of parents and professionals for the OAA newsletter. Because this database will eventually replace the current mailing list, you must return a completed questionnaire to continue to receive the newsletter. The name and address portion is absolutely required to enter the database for future mailings. Other information will ONLY be given to other OAA parents/professionals as requested for matching or research purposes.

(*) denotes required fields.

Contact Information

*Choose one of the following options:

Responsible Adult's Name(s) (first, last, middle initial):

*#1
#2

*Would you like to receive our Newsletter?

I currently receive the newsletter by postal mail. No Thank you. Sign me up!

Please provide the following contact information:

*Street address
*City
*State/Province
*Zip/Postal code
*Country
*Home Phone
Work Phone
Fax
*E-mail
URL

Professional Information

Title
Organization
Street address
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail
URL

Patient Information

*Patient Relationship:
If deceased (date):	mm/dd/yyyy
Full Name:
MI:
Date of birth:	mm/dd/yyyy
Sex:	Male Female
Height:
Weight:
*Diagnosis:
Secondary Diagnosis:

Please choose one of choices from 0 to 5: (5 = above average, 3 = average, 0 = below average)
Height:	0 1 2 3 4 5
Weight:	0 1 2 3 4 5
Hearing:	0 1 2 3 4 5
Vision:	0 1 2 3 4 5
Mental Functioning:	0 1 2 3 4 5
Speech/Communications:	0 1 2 3 4 5
Mobility:	0 1 2 3 4 5
Speech:	Speaking Device Sign Language Neither
Wheel Chair:	Yes No
Muscle Tone:
Neurology/Brain:
Organ Damage:
Behavior:
Feeding/Appetite:
Other:
Special Diet:
Medications:
Dietitian/Nutritionist Name:
Dietitian/Nutritionist Facility:
Metabolic/Genetic Physician Name(s):
Metabolic/Genetic Facility:
Regular Physician Name:
Regular Physician Facility:
Formula:
Vitamins:

Your interest in OAA

What article/information would you like to see in future newsletters?
*Would you be willing to contribute an article for future newsletters?	Yes No
On what Topic?
*May we use this info to match you with other interested parents/professionals?	Yes No
*May we use the name and address info in a membership roster for parents/professionals?	Yes No
Comments: