CLINICAL INFORMATION for chromosome imbalance testing Place an X in the box if statement applies to the subject. – Typical 1 Cognitive Development Delay (Atypical) Mild (IQ 50-69; for adults mental age 9-12 yrs) Mod (IQ 35-49; for adults mental age 6-9 yrs) Severe (IQ 20-34; for adults mental age 3-6 Profound (IQ <20; for adults mental age <3 years) 2 Specific Developmental Speech and language Reading and spelling Arithmetic Skills Disorder Autistic Spectrum Disorder Yes No 3 Neurodevelopmental/Behavioral ADHD Yes No Problems Tics Yes No Yes No Feeding Yes No Psychosis Yes No Other behavioral problems Yes No Vision Hearing Abnormal tone/involuntary movements Structural brain lesion 4 Neurological Disorders Cerebral Palsy Unilateral Cerebral Palsy Bilateral Epilepsy Age of onset <3 months 3-24 months > 24 months At birth Small for gestational age (<10th centile) Yes No 5 Growth Abnormalities At Large for gestational age (>90th centile) Yes No Current: Tall stature (height >95th centile) Yes No Short Stature (height < 5th centile) Yes No Macrocephaly (>95th centile) Yes No Microcephaly (<5th centile) Yes No Heart disease (e.g. ASD, VSD) Yes No 6 Congenital Malformations/Dysmorphism Renal and Urogenital malformations Yes No Malformations Yes No Eye malformations (e.g. anophthalmia, microphthalmia) Yes No Ear malformations Yes No Cleft lip Cleft palate Micrognathia Yes No Limb abnormalities (e.g. short or long bones) Yes No Digital abnormalities (e.g. syndactyly, polydactyly) Yes No Facial dysmorphism e.g. hypertelorism Yes No 7 Endocrine and metabolic Yes No conditions 8 Cutaneous stigmata/skin Yes No lesions 9 Hair, nail, teeth abnormalities Yes No 10 Other Skeletal abnormalities Yes No eg scoliosis
CLINICAL INFORMATION – for chromosome imbalance testing Place an X in the box if statement applies to the subject. 1 Cognitive Development Typical Delay (Atypical) Mild (IQ 50-69; for adults mental age 9-12 yrs) Mod (IQ 35-49; for adults mental age 6-9 yrs) Severe (IQ 20-34; for adults mental age 3-6 Profound (IQ <20; for adults mental age <3 years) 2 Specific Developmental Disorder Speech and language Reading and spelling Arithmetic Skills 3 Neurodevelopmental/Behavioral Problems Autistic Spectrum Disorder Yes No ADHD Yes No Tics Yes No Yes No Feeding Yes No Psychosis Yes No Other behavioral problems Yes No 4 Neurological Disorders Vision Hearing Abnormal tone/involuntary movements Structural brain lesion Cerebral Palsy Unilateral Cerebral Palsy Bilateral Epilepsy Age of onset <3 months 3-24 months > 24 months 5 Growth Abnormalities At birth Small for gestational age (<10th centile) Yes No At Large for gestational age (>90th centile) Yes No Current: Tall stature (height >95th centile) Yes No Short Stature (height < 5th centile) Yes No Macrocephaly (>95th centile) Yes No Microcephaly (<5th centile) Yes No 6 Congenital Malformations/Dysmorphism Heart disease (e.g. ASD, VSD) Yes No Renal and Urogenital malformations Yes No Malformations Yes No Eye malformations (e.g. anophthalmia, microphthalmia) Yes No Ear malformations Yes No Cleft lip Cleft palate Micrognathia Yes No Limb abnormalities (e.g. short or long bones) Yes No Digital abnormalities (e.g. syndactyly, polydactyly) Yes No Facial dysmorphism e.g. hypertelorism Yes No 7 Endocrine and metabolic conditions Yes No 8 Cutaneous stigmata/skin lesions Yes No 9 Hair, nail, teeth abnormalities Yes No 10 Other Skeletal abnormalities eg scoliosis Yes No
MF-G-Request-form.docx