Clinical History Form Click here to download – clinical information sheet>>>PATIENT consent form >>> Web Site 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 Ataxia Autism in family Behaviour abnormalities Dark circles under the eyes Deafness Dementia in family Depression Destructive behaviour Down’s syndrome Dysmorphic features Epichantic folds (ears) Flushed cheeks / face Hyperactive Hyper-accuses (hearing) Insomnia Irritability (severe) Lack of eye contact Learning disability Lethargy / coma Loss of speech Mental retardation Migraine / Headache OCD (Obsessive-compulsive disorder) Parkinson’s in family PDD (pervasive developmental delay) Photophobia (sensitivity to light) Poor concentration Restless Schizophrenia in family Seizures Self-mutilation / self-injury Speech delay Unexpected throat clearing White blotches on face Withdrawn MRI MRI Brain done EEG EEG done Motor / Muscular Hypertonia (toe walkers) Hypotonia (muscle weakness) Loss of meaningful hand use Motor Neuron Disease Motor-Vocal Tics (Tourette’s syndrome) Multiple Sclerosis Psychomotor delays Spasticity Movement Movement Disorder Abdomen Coeliac disease Diarrhoea Eating disorders Enlarged liver Enlarged spleen Poor sucking reflex Severe Constipation Vomiting (projectile or otherwise) Feeding Problems Feeding Problems Skin / Hair / Nails Abnormal hair growth Mild Acne Severe Acne Café o’lait markings Dermatitis Diminishing 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 infection history Increased fungal infection history Increased viral infection history Melanomas Blood / Heart Anaemic Arteriosclerosis Bruises easily Congenital heart defect Family history of heart disease 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 Growth retardation Rheumatoid arthritis Skeletal degeneration Weak motor integration Abnormal gait Skeleteal Abnormal Skeleton Endocrine Diabetes type 1 Diabetes type 2 Underactive thyroid function Overactive thyroid function Syndactyly Webbing between fingers or toes Syndactyly fingers Syndactyly toes Syndactyly fingers and toes Miscellaneous Indicate female siblings 1 2 3 4 5 6 7 8 9 10 Indicate male siblings 1 2 3 4 5 6 7 8 9 10 How many siblings show the same clinical symptoms as the patient? 1 2 3 4 5 6 7 8 9 10 Sudden death Sudden Infant Death Syndrome in family Prev Baby Previous baby / babies died of unknown causes (this includes relatives as well) Fever attacks Fever attacks Sleep Sleep disturbance Strange odour Strange 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
