Clinic / Home Visit - Saliva Collection (Mother)

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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