ABAT

Parent Upload Clinical Information

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Remarks

Details Parents
Email
First Name		Last Name
City		Country
Details patient
PMID		Patient Identification Number
Age of Last Examination		Country
Gender
Pregnancy, childbirth and neonatal period
At how many weeks of pregnancy was your child born?		Weeks & Days
Birth
What was the birth weight?
Did your child have a low birth weight?
Did your child have a high birth weight?
How was your child’s head circumference at birth?
What was your baby’s Apgar score after 1 minute?
What was your baby’s Apgar score after 5 minutes?
What was your baby’s Apgar score after 10 minutes?
Did your baby require extra oxygen immediately after birth?
Did your baby have jaundice that needed treatment?
In the first three months after the birth, did your baby have problems feeding?
In the first three months after the birth, did your baby feel floppy (hypotonia)?
In the first three months after the birth, did your baby show signs of epilepsy?
Growth
What height is your child at the moment?
How is your child’s head circumference at the moment?
How is your child’s weight at the moment?
Has your child been diagnosed with a growth hormone deficiency?
When was your child’s last growth measurement? (yyyy/mm/dd)
What was your child’s height then? (cm)
What was your child’s weight then? (kg)
What was your child’s head circumference then? (cm)
Height of biological father in cm
Height of biological mother in cm
Development
Is your child showing signs of developmental delays?
If yes: In which areas?
Is there evidence of a cognitive impairment?
Has your child's IQ ever been tested?
If yes: How old was your child when he/she last had an IQ test?		Years & Months
If yes to question in row 67: What was the result of the last IQ test (total IQ)?
Has your child lost any skills that he/she had previously mastered?
How old was your child when he/she rolled over for the first time?
How old was your child when he/she sat unassisted for the first time?
How old was your child when he/she took his/her first steps unassisted?
How old was your child when he/she said his/her first words?
Does your child have urinary incontinence?
Does your child have stool incontinence?
Speech and language
Has your child been diagnosed with delayed speech/language development?
Does your child drool excessively?
Does he/she have an open mouth posture?
Does or did he/she have any abnormal structures in the mouth area?
If yes, which?
Is it possible to communicate verbally with your child?
Does your child speak more than ten words?
Does your child use assisted communication?
Does your child have difficulty using language to communicate his/her needs, wishes or thoughts?
Does your child understand everything that is said to him/her?
Has a speech therapist made a speech diagnosis?
If yes, which?
General day-to-day skills
Can your child bathe or shower?
Can your child dress and undress him/herself?
Can your child go to the bathroom?
Can your child eat independently?
Does your child have difficulty climbing stairs independently?
Does your child have difficulty running?
Can your child read? (yes/no)
If yes: How old was your child when he/she learned to read?
Can your child write?
If yes: How old was your child when he/she learned to write?
Does your child have difficulty walking?
Does your child often bump into things or fall?
Behavior and sleep
Do you find your child's behavior problematic?
Has your child been diagnosed with a mental illness?
If yes, which?
Is your child often anxious?
Is your child very withdrawn?
Is your child easily distracted?
Does your child often fidget and wiggle about?
Is your child's sleep behavior problematic?
Does your child fall asleep easily?
Does your child sleep through the night?
Neurology
Has your child had febrile seizures?
Has your child ever had an epileptic seizure?
If yes: At what age did your child have his/her first epileptic seizure?		Years & Months
If yes: How long ago was his/her last epileptic seizure?		Years & Months
If yes: Roughly how many seizures does your child have per month?
If yes: What kind of seizures does your child have?
Has your child ever had an EEG (brain test)?
Was the result abnormal?
Has your child ever had a brain scan?
If yes: Which examination did he/she have?
Were any brain abnormalities seen?
If yes: What brain abnormalities were seen?
Hearing and vision
Have your child's eyes ever been examined?
Can your child see well?
Does your child wear glasses?
Does your child have any other vision problems?
If yes, please explain
Can your child hear well?
If no:
Does your child have a hearing aid?
Heart defects
Does your child have a heart defect?
If yes: Hole in the septum (ASD)
If yes: Hole in the chambers of the heart (VSD)
Tetralogy of Fallot
Underdeveloped left part of the heart (hypoplastic left heart syndrome)
Problem with one of the heart valves
Arrhythmia
Other, namely...
Lung disease
Does your child have lung disease?
If so, what kind?
Feeding and gastrointestinal problems
Does your child have/has your child ever had problems feeding?
Does your child choke easily?
Does your child have/has your child ever had a feeding tube?
Kidneys and urinary tract
Does your child have kidney problems?
If so, what kind?
Skeleton
Does your child have bone/skeletal problems?
Does your child have a scoliosis? (spine twisted to one side/bend in the spine)
If yes: What treatment is your child having/has your child had for his/her scoliosis?
Does your child have flat feet?
Does your child have a pigeon chest or funnel chest?
Does your child have spinal problems?
Does your child have any other muscle or bone problems?
Skin and teeth
Does your child have eczema?
Does your child have very pale or dark patches on the skin?
Does your child have dental abnormalities?
Does your child have any other skin or dental problems?
Does your child have any allergies or has he/she ever had an allergic reaction?
Hormonal
Has your child been diagnosed with a thyroid problem?
What kind of thyroid problem has been diagnosed?
Has your child been diagnosed with diabetes?
What type of diabetes has been diagnosed?
Has your child ever been diagnosed with high blood pressure?
Age of first period (year)		Years & Months
Immune system
Do you find that your child is often sick?
Does your child get frequent colds?
Has your child had repeated bouts of lung infection?
Does your child often have ear infections?
Does your child often have bladder infections?
Has your child been diagnosed with problems in the immune system?
Other
Has your child undergone any other operations?
Which ones and at what age?
Does your child take medications?
Which ones?
Does your child have any characteristics that you think are important and that have not been covered in this questionnaire?