Maybe It's Mito - GP Sign-up

Thank you for completing the "Maybe It's Mito" module.

By completing this module, you are now better informed to identify mitochondrial disease (mito) and reduce the time it takes for people with mito to be diagnosed. Please provide a few more details for our Mito Professionals Directory which aims to help treat patients with mito.

By joining the Directory you will also gain access to more information about mito, the Medical Practitioners pack as well as access to mitochondrial disease specialists and other educational resources.

We will not publish your details anywhere online.

Mito Professionals Directory

Name
First Last
Medical speciality or allied health field (e.g. Neurologist, Geneticist, Nurse Practitioner, Dietitian, etc)
What is your role?
Clinic's Address (this will not be shared publicly)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (this will not be shared publicly)
Email (this will not be shared publicly)
Do you work with a multidisciplinary clinic that can offer additional services to mito patients? (For example: nutrition services, occupational therapy, or genetic counselling.) If yes, please provide details.
Are you able to provide telehealth consults? (Please provide details.)
Age of patients seen:
- Adult patients
- Paediatric patients
- Both
Would you like to subscribe to the Mito Foundation's communications, including e-newsletter and other updates
- Yes
- No, not at this moment

Thank you for completing the "Maybe It's Mito" module.

Mito Professionals Directory

1. On a scale from 0 to 5 (where 0 is very poor knowledge, and 5 is all the knowledge you feel you need), how would you rate your knowledge?

2. On a scale from 0 to 5 (where 0 is very poor confidence and 5 is all the confidence you feel you need), how would you rate your confidence?

3. On a scale from 0 to 5 (where 0 is very poor wellbeing, and 5 is what you feel your wellbeing should be), how would you rate your wellbeing?

4. On a scale from 0 to 5 (where 0 is very poor access to the services you need, and 5 is you have access to the services you feel you need), how would you rate your access to services:

Thank you for completing the "Maybe It's Mito" module.

Mito Professionals Directory

Send us feedback about this resource

1. On a scale from 0 to 5 (where 0 is very poor knowledge, and 5 is all the knowledge you feel you need), how would you rate your knowledge?

2. On a scale from 0 to 5 (where 0 is very poor confidence and 5 is all the confidence you feel you need), how would you rate your confidence?

3. On a scale from 0 to 5 (where 0 is very poor wellbeing, and 5 is what you feel your wellbeing should be), how would you rate your wellbeing?

4. On a scale from 0 to 5 (where 0 is very poor access to the services you need, and 5 is you have access to the services you feel you need), how would you rate your access to services: