Clinical History Form Click here to download >>> Order Number Healthcare Professional’s details Title Mr. Dr. Prof. Mrs. Ms. Name * Surname * Phone Number * Fax E-mail Patient Information Name of patient Surname of patient Date of birth Gender Male Female Age at onset of symptoms Patient’s clinical information Please mark applicable information, in order to assist with the analysis and interpretation of the results. Head / Neurologic Abnormal ears (e.g. red) Abnormal face Aggressive behavior Alzheimer’s in family Amnesia in family Aneurysms (bleeding in brain) Ataxia Autism in family Behavior abnormalities Dark circles under the eyes Deafness Dementia in family Depression Destructive behavior Down’s syndrome Dysmorphic features Epichantic folds (ears) Flushed cheeks / face Hyperactive Hyper-acusis (hearing) Insomnia Irritability (severe) Lack of eye contact Learning disability Lethargy / coma Loss of speech Mental retardation Migraine / Headache (severe) Obsessive-compulsive disorder Parkinson’s in family PDD (pervasive developmental delay) Photophobia (sensitivity to light) Poor concentration Restless (severe) Schizophrenia in family Seizures Self-mutilation / self-injury Speech delay Unexpected throat clearing White blotches on face Withdrawn (severe) MRI MRI Brain done EEG EEG done Motor / Muscular Hypertonia (toe walkers) Hypotonia (muscle weakness) Loss of meaningful hand use Motorneuron disease Moto-vocal tics (Tourette’s syndrome) Multiple scierosis Psychomotor delays Spasticity Movement Movement Disorder Abdomen Coeliac disease Constipation (severe) Diarrhoea Eating disorders Enlarged liver Enlarged spleen Poor sucking reflex Vomiting (projectile or otherwise) Feeding Problems Feeding Problems Skin / Hair / Nails Abnormal hair growth Acne (severe) Cafe o’lait markings Dermatitis Diminishing / Increased pigmentation Dry, brittle hair Eczema Hives / itching (severe) Impaired wound healing Increased pigmentation Loss of hair Photosensitive Skin rashes Eyes Optic neuritis Recurrent otitis media Eye Abnormalities (please describe) Eye Abnormalities Immunity Hyper IgE syndrome Increased bacterial infections (e.g. repeater ear, nose, throat infections) Increased fungal infections Increased viral infections Melanomas Blood / Heart Anaemic Arteriosclerosis Bruises easily Congenital heart defect Family history of heart diseases Haemophiliacs (bleeders) Apnoea (breathing stops while asleep) History of Thrombosis Mouth Abnormal teeth Abnormal tongue (includes sores in mouth and on tongue) Cleft palate Excessive drooling Halitosis (very bad breath / acetone on breath) High palate Low oral tone (Mouth hangs open) Skeletal Abnormal skeleton Growth retardation Rheumatoid arthritis Skeletal degeneration Weak motor integration Abnormal gait Endocrine Diabetes type 1 Diabetes type 2 Under- / overactive thyroid Underactive thyroid function Overactive thyroid function Syndactyly Webbing between fingers or toes Syndactyly fingers Syndactyly toes Syndactyly finders and toes Miscellaneous Indicate female siblings Indicate male siblings How many siblings show the same clinical symptoms as the patient? Sudden death Sudden Infant Death Syndrome in family Prev Baby Previous baby / babie’s died if unknown causes (this includes relatives as well) Fever attacks Fever attacks Sleep Sleep disturbances Strange odour Stange body odour observed Weight Sudden weight gain WeightL Sudden weight loss Collection Sample collection for testing done when the symptoms were most prominent Collections Sample collection for testing done when the symptoms were NOT most prominent Medication / supplements / treatment the patient was on during sample collection Other relevant information Reset? Yes
