LC-FAOD Self-Care Assessment
(continued)

Patient Name : Patient Name Date: 12/31/2023

How is LC-FAOD impacting you or your loved one’s life?

Take this assessment to find out and to identify topics to discuss with your healthcare team.

Contact your healthcare team if any symptoms concern you.

Activity and Symptoms

Are you/your loved one happy with your/their current level of activity?

Yes

Are you or your loved one missing, avoiding or limiting physical activities (i.e. walking, exercise, social activities, school, work, etc.)?

How often? do not at all .

Are you/your loved one experiencing any of the following symptoms?.

Ongoing/Always (Chronic) Symptoms

None.

Occasional/Sometimes (Acute) Symptoms

None.

When do you/your loved one experience these symptoms?

Symptoms last for:

Are any of these symptoms new or have they recently changed?

Yes

Explain further:

How would you rate your recent pain level?:

1 (1-Min, 10-max)

What typically triggers these symptoms?

None.

Please specify:

Clinical Follow Up

How often do you meet with your LC-FAOD healthcare team (i.e., dietitian, genetic counselor, nurse, metabolic geneticist, other physician, etc.)?
Not at all.

Do you have an appointment scheduled ?

Date of next appointment:

Are you seeing any other specialists?

Yes

Please specify:

Preparation for Discussion

Have you/your loved one experienced any other issues or challenges (social situations, mental health, school, workplace issues, etc.) while living with LC-FAOD?

Yes

Please describe:

Thinking back on your last several visits with your healthcare team, what else would you like to share about living with LC-FAOD?

Are there any life goals you have that LC-FAOD has limited you from achieving? List any additional questions or issues to discuss with your healthcare team:

LC-FAOD Self-Care Assessment (continued)

LC-FAOD Self-Care Assessment
(continued)