Clinic / Home Visit - Saliva Collection (Mother)

The Study to Explore Early Development (SEED) - Phase 3

Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17

Clinic / Home Visit - Saliva Collection (Mother)

OMB: 0920-1171

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Gender (circle one): Male / Female ID#:___________________________________

Date of Birth: Date of examination:

Examiner:


Scale QC - Use object of known weight

Record weight here (including units):

Initial Scale reading with object


COMMENTS

(Type of object used)




MOTHER’S MEASUREMENTS

Biological MOTHER

Measurement

Exam Comments

Height Specify Units


 unreliable – reason___________________________

 not present, so reported

Head Circumference (cm)


 unreliable – reason__________________________



CHILD’S MEASUREMENTS

Growth Parameters

Measurement

Exam Comments

Height (cm)


 unreliable – reason__________________________

Weight (kg)


 unreliable – reason__________________________

Head Circumference (cm)


 unreliable – reason__________________________


1) Was [CHILD] born with any problems in the structure of his/her body or organs (also know as birth defects)?

 No

 Yes - describe ____________________________________


2) Has [CHILD] had any corrective surgeries? This includes surgeries to repair problems in the abdominal or genital region (such as hernias)?

 No

 Yes - describe ____________________________________


3) Does [CHILD] have a diagnosis of a genetic syndrome?

 No

 Possible Dx*:___________________________

 Yes Dx*: ______________________________


4) Has [CHILD] had a genetics evaluation, blood tests for problems with genes or chromosomes, or been seen by a genetics doctor or genetic counselor?

 No

 Yes* Reason/Results:___________________________



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