SLC35A2 Clinical Survey

Terms of Use*
– I agree and acknowledge that I am authorized to provide the following information about myself, my family and the person(s) diagnosed with SLC35A2-CDG listed hereafter.
Please select your Relationship to the patient:*
Has your child received a confirmed diagnosis of SLC35A2-CDG?:*
Do you have more than one family member diagnosed with SLC35A2-CDG?:*
Please complete and submit this form once for each family member that has been diagnosed with SLC35A2-CDG.
Your Name*
First Last
Your Email*

Email address is only collected so that we may contact you if we have questions about any data provided.
Please select the Country where the patient resides from the following list:*
Country
Is the patient currently enrolled in the Frontiers in CDG Consortium (FCDGC) Natural History Study at Mayo Clinic, CHOP, Seattle Children’s or any affiliated FCDGC clinic?:*
Please provide the Name of the patient:*
First Last
Please provide the Date of Birth of the patient:*
Month
Day
Year
Please provide the Gender of the patient:*
Does your child have the following? (Please select all that apply):*
- Constipation
- Diarrhea
- Vomiting/feeding intolerance
How much do you feel GI-related issues affect your child’s well-being?:*
Does your child regularly take medications for GI-related issues?:*
With what frequency does your child use GI-related medications?:*
Does your child have “as needed” or “PRN” GI medication in addition to a regularly taken GI medication?:*
If yes to the question above, how frequently does your child typically need to use “as needed” or “PRN” medications in addition to a regular GI medication?:*
In the last year, how many times has your child needed to go to the Emergency Department or required hospitalizations for GI-related issues?:*
Name
This field is for validation purposes and should be left unchanged.