Join LGDA Patient Matching Program - Lymphangiomatosis & Gorham's Disease Alliance

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Join LGDA Patient Matching Program

Patient Matching Registration Form

Today's Date
MM slash DD slash YYYY
PLEASE TELL US ABOUT THE PATIENT
Name*
First Last
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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?
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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Raising Awareness

Twenty years of never knowing another person with my disease inspired me to help others. Jana Sheets, LGDA Founder, USA

Patient Support

LGDA is here to help you find resources and to provide support to patients and families living with Gorham-Stout disease (GSD) & lymphangiomatosis/generalized lymphatic anomaly (GLA).

Click Here to Email Us

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