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What is lymphangiomatosis?
What is Gorham’s Disease?
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Today's Date
Date Format: MM slash DD slash YYYY
PLEASE TELL US ABOUT THE PATIENT
Name
*
First
Last
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
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Aruba
Australia
Austria
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Belarus
Belgium
Belize
Benin
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Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
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Djibouti
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Dominican Republic
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El Salvador
Equatorial Guinea
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Eswatini (Swaziland)
Ethiopia
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French Polynesia
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Gabon
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Georgia
Germany
Ghana
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Guinea
Guinea-Bissau
Guyana
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Heard and McDonald Islands
Holy See
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Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
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Lebanon
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Lithuania
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Namibia
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New Caledonia
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Niger
Nigeria
Niue
Norfolk Island
North Korea
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Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
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Singapore
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Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
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Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Email
*
What is the patient's diagnosis?
*
Generalized lymphatic anomaly (GLA) / lymphangiomatosis
Gorham-Stout Disease (GSD)
Kaposiform lymphangiomatosis (KLA)
Central conducting lymphatic anomaly (CCLA)
Other or not sure
What areas of the patient's body are effected? Check all that apply:
*
Chest
Abdomen
Bones
Skin
What symptoms have been experienced? Check all that apply.
*
Pain
Fluid Collection(s)
Fracture
Cough/wheezing/difficulty breathing
Severe fatigue (patient unable to attend school/work/activities at least once a week)
slow growth/malnourishment
Fever not associated with acute illness
Frequent infection
Nausea/Vomiting
Diarrhea
Rash
None of the above
What is the name of the patient's main doctor for lymphangiomatosis/Gorham's disease?
What is this doctor's area of specialty?
Pediatrician
Family Medicine
Internal Medicine
Cardiology/Pediatric Cardiology
Pulmonology/Pediatric Pulmonology
Gastroenterology/Pediatric GI
Orthopedics/Pediatric Ortho
Hematology-Oncology/Pedicatric Hem-Onc
Dermatology/Pediatric Derm
Neurology/Pediatric Neuro
Surgeon/Pediatric Surgeon
Other
Don't Know/Not Sure
please select from the drop-down menu
Please enter the name of the clinic/hospital where the patient receives most of his/her care for lymphangiomatosis/Gorham's
*
Please include the city and state where this facility is located.
ABOUT THE PERSON COMPLETING THE FORM
Name of person completing form
*
First
Last
I am the:
*
Patient
Parent or Legal Guardian with whom the patient resides
Parent or Guardian with whom the patient does NOT reside
Spouse of the patient
other
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