Test request form - Pliem at the North-West University

Healthcare Professional’s details

Title

Name

Surname

Phone Number

Fax

E-mail

Patient Information

Name of patient

Surname of patient

Date of birth

Gender

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.

Miscellaneous

Indicate female siblings

Indicate male siblings

How many siblings show the same clinical symptoms as the patient?

Sudden Infant Death Syndrome in family

Previous baby / babies died of unknown causes (this includes relatives as well)

Fever attacks

Sleep disturbance

Strange body odour observed

Sudden weight gain

Sudden weight loss

Sample collection for testing done when the symptoms were most prominent

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

Clinical History Form