Patient Information And Referral Form
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3Patient Information and Referral Form
PATIENT INFORMATION
REFERRING CLINICIAN INFORMATION
First name:
Name:
Family name:
or Unique Identification number:
Address:
Date of birth (dd/mm/yyyy):
Sex:
Male
Female
Email:
Geographic origin of patient:
DIAGNOSES:
Adrenal insufficiency (Addison disease)
Hypoparathyroidism
Diabetes mellitus
Hypogonadism
Hypoaldosteronism
Pernicious anemia
Pituitary defects:
GH
TSH
PRL
ACTH
LH/FSH
ADH
Basal Level:
_______
_______ _______ _______ _______
_______ (Units ?)
Stimulated:
_______
_______ _______ _______ _______
_______ (Units ?)
CLINICAL FEATURES:
Age at diagnosis:
Early infancy (0-1 ys)
Infancy (2-5 ys)
Childhood / Adolescence (6-18 ys)
Symptoms leading to diagnosis:
Prolonged Jaundice
Candidiasis
Extodermal dystrophy
Vitiligo
Hypoglycaemia
Keratopathy
Cholelithiasis
Hepatitis
Umbilical hernia
Asplenia
Chronic atrophic gastritis
Birth Weight:_________
Alopecia
Dental enamel hypoplasia
Birth Height:__________
Diarrhea
Malabsorption
Dysmorphic features:
Neurological deficits:
Cardiac malformations:
Others:
Onset of puberty
not yet
yes, spontaneous at age of
Hypogonadism
Menarche
not yet
yes, spontaneous
at age of
Johannes FW Weigel and Roland W Pfäffle (2004)
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Parent category: Medical