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MitoAction Mito Community Survey

Demographics
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1. What is your connection to mito? *This question is required.
Diagnosis
2. Who was the driver of the genetic testing?  (choose all that apply) *This question is required.
2. What type of mitochondrial disease were you diagnosed with? *This question is required.
2. What type of mitochondrial disease was the affected individual diagnosed with? *This question is required.
2. Why have you not completed genetic testing? *This question is required.
2. Why has the affected individual not completed genetic testing? *This question is required.
2. Which other members of your family have a clinical or genetic diagnosis of mitochondrial disease? *This question is required.
2. Which other members of the affected individual's family have a clinical or genetic diagnosis of mitochondrial disease? *This question is required.
2. Please choose any responses that apply to this statement: No one else your family ... *This question is required.
2. Please choose any responses that apply to this statement: No one else in the affected individual's family ... *This question is required.
2. To what degree do you feel you had to advocate for genetic testing? *This question is required.
Not at allOnly a littleTo some extentRather muchVery much
2. To what degree do you feel the affected individual had to advocate for genetic testing? *This question is required.
Not at allOnly a littleTo some extentRather muchVery much
Symptoms/Treatment
2. What are your most common symptoms? *This question is required.
2. What are the affected individual's most common symptoms? *This question is required.
2. What is the severity of your muscle pain? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's muscle pain? *This question is required.
NoneMildModerateSevere
2. What is the severity of your muscle fatigue? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's muscle fatigue? *This question is required.
NoneMildModerateSevere
2. What is the severity of your pain - general? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's pain - general? *This question is required.
NoneMildModerateSevere
2. What is the severity of your brain fog / confusion? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's brain fog / confusion? *This question is required.
NoneMildModerateSevere
2. What is the severity of your lack of energy? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's lack of energy? *This question is required.
NoneMildModerateSevere
2. What is the severity of your shortness of breath? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's shortness of breath? *This question is required.
NoneMildModerateSevere
2. What is the severity of your balance coordination problems? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's balance coordination problems? *This question is required.
NoneMildModerateSevere
2. What is the severity of your arrhythmia? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's arrhythmia? *This question is required.
NoneMildModerateSevere
2. What is the severity of your seizures? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's seizures? *This question is required.
NoneMildModerateSevere
2. What is the severity of your rhabdomyolysis? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's rhabdomyolysis? *This question is required.
NoneMildModerateSevere
2. What is the severity of your exercise intolerance? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's exercise intolerance? *This question is required.
NoneMildModerateSevere
2. What is the severity of your dysautonomia? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's dysautonomia? *This question is required.
NoneMildModerateSevere
2. What is the severity of your hypotonia? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's hypotonia? *This question is required.
NoneMildModerateSevere
2. What is the severity of your growth issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's growth issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your weight gain? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's weight gain? *This question is required.
NoneMildModerateSevere
2. What is the severity of your developmental issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's developmental issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your vision issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's vision issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your heart issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's heart issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your kidney issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's kidney issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your GI issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's GI issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your endocrine issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's endocrine issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your breathing issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's breathing issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your mental health issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's mental health issues? *This question is required.
NoneMildModerateSevere
2. What is the severity of your neuropathy? *This question is required.
NoneMildModerateSevere
2. What is the severity of the affected individual's neuropathy? *This question is required.
NoneMildModerateSevere
2. What do you feel is most understood about mitochondrial disease? *This question is required.
2. What topics are important for you to have resources to better manage your day-to-day with mitochondrial disease? *This question is required.
3. How much care do you require during an average day? *This question is required.
No care - completely independantSome careFull care
3. How much care does the affected individual require during an average day? *This question is required.
No care - completely independantSome careFull care
3. What healthcare professionals are currently involved in managing your mitochondrial disease? *This question is required.
3. What healthcare professionals are currently involved in managing the affected individual's mitochondrial disease? *This question is required.
Future Planning
3. To what degree do you feel a developmental disability contributes to your level of independence? *This question is required.
Not at allOnly a littleTo some extentRather muchVery much
3. To what degree do you feel a developmental disability contributes to the affected individual's level of independence? *This question is required.
Not at allOnly a littleTo some extentRather muchVery much
3. To what degree do you feel a physical disability contributes to your level of independence? *This question is required.
Not at allOnly a littleTo some extentRather muchVery much
3. To what degree do you feel a physical disability contributes to the affected individual's level of independence? *This question is required.
Not at allOnly a littleTo some extentRather muchVery much
Employment
3. Which of the following have impacted your ability to perform at work? *This question is required.
3. Which of the following have impacted the affected individual's ability to perform at work? *This question is required.
Relationships
3. Does having a mitochondrial disease impact the following relationship? *This question is required.
Space Cell NeverRarelySometimesOften
Relationships in general
Professional relationships
Romantic Relationships
Family Relationships
Friendships
Mental Health
3. Which of the following mental health issues have you experienced? *This question is required.
3. Which of the following mental health issues has the affected indiviudal experienced? *This question is required.
3. Which of the following methods have been used to treat your mental health issues? *This question is required.
3. Which of the following methods have been used to treat the affected individuals mental health issues? *This question is required.
3. Have you ever been bullied or teased about any of the following due to mitochondrial disease? *This question is required.
3. Has the affected individual ever been bullied or teased about any of the following due to mitochondrial disease? *This question is required.
3. How often do you... *This question is required.
Space Cell NeverRarelySometimesOften
Feel lonely/isolated due to mitochondrial disease?
Worry about the uncertainty of your future related to your health care?
Worry about your financial situation?
Worry about access to medical care?
Worry about access to medications?
3. How often does the affected individual... *This question is required.
Space Cell NeverRarelySometimesOften
Feel lonely/isolated due to mitochondrial disease?
Worry about the uncertainty of their future related to their health care?
Worry about their financial situation?
Worry about access to medical care?
Worry about access to medications?
3. Is your family? *This question is required.
3. Is the affected individual's family? *This question is required.
3. Is your home state? *This question is required.
3. Is the affected individual's home state? *This question is required.
3. Where do you seek support? *This question is required.
3. Where does the affected individual seek support? *This question is required.
Access to Care
3. Why are you not seeing a mitochondrial disease expert? *This question is required.
3. Why does the affected individual not see mitochondrial disease expert? *This question is required.
Clinical Trials
3. What reason(s) would you consider participating in a clinical trial? *This question is required.
3. What reason(s) would the affected individual consider participating in a clinical trial? *This question is required.
3. What reason(s) would you not consider participating in a clinical trial? *This question is required.
3. What reason(s) would the affected individual have for not considering participating in a clinical trial? *This question is required.
3. How do you learn about clinical trials? *This question is required.
3. How does the affected individual learn about clinical trials? *This question is required.
3. What do you feel should be the research priorities for mitochondrial disease? *This question is required.
Support
4. What type of support groups would you be interested in participating in? *This question is required.
4. What type of support groups would the affected individual be interested in participating in? *This question is required.
4. When is the best time of day to attend support group calls? *This question is required.
5. What day(s) of the week are best to attend support group calls? *This question is required.
6. I would like more information on the following programs... *This question is required.