Microarray Test Requisition Form Page 2
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2Patient Acct No.
Patient Name (Surname First)
MICROARRAY
Patient Unit No.
CLINICAL DESCRIPTION FORM
D.O.B.
Sex
GENETICS LABORATORY - Credit Valley Hospital
2200 Eglinton Ave. W., Rm 2H144
Tel: (905) 813-1100 x6288
Address/City/Province/Postal Code
Mississauga, ON L5M 2N1 Canada
Fax: (905) 813-3854
Health Card Number
Version
Phenotypic description (Clinical symptoms)
Behavior, Cognition and Development
Cardiac
Respiratory
Global development delay
ASD
Diaphragmatic hernia
Gross motor delay
VSD
Lung abnormality (Specify below)
Fine motor delay
AV canal defect
Other: _______________________
Language delay
Coarctation of aorta
Learning disability
Tetralogy of fallot
Musculoskeletal
Intellectual disability
Other: _______________________
Upper limb abnormality
Mild
Lower limb abnormality
Craniofacial
Moderate
Camptodactyly
(
finger /
toe)
Severe
Craniosynostosis
Syndactyly
(
fingers /
toes)
Attention deficit hyperactivity disorder
Cleft lip
Cleft palate
Polydactyly
(
finger /
toe)
Autism Spectrum Disorder
Micrognathia
Retrognathia
Preaxial
Psychiatric disorders
(specify below)
Facial dysmorphism
(specify below)
Postaxial
Other: _______________________
Other: _______________________
Oligodactyly
(
finger /
toe)
Clinodactyly
(
finger /
toe)
Neurological
Eye Defects
Contractures
Hypotonia
Blindness
Scoliosis
Seizures
Coloboma
Vertebral Anomaly
Ataxia
Epicanthus
Club foot
Dystonia
Hypertelorism
Other: _______________________
Chorea
Eyelid abnormality
(specify below)
Gastrointestinal
Spasticity
Other: _______________________
Esophageal atresia
Cerebral palsy
Tracheoesophageal fistula
Neural tube defect
Ear Defects
Gastroschisis
Abnormality of the CNS
(specify below)
Deafness
Omphalocele
Preauricular
Other: _______________________
Pyloric stenosis
Low-set ears
Outer ear abnormality
(specify below)
Other: _______________________
Growth Parameters
Less
Greater
Inner ear abnormality
(specify below)
than
than
Genitourinary
Other: _______________________
Weight for age:
3rd %
97th %
Kidney malformation (Specify below)
Stature for age:
3rd %
97th %
Hydronephrosis
Cutaneous
Ambiguous genitalia
Head circumference:
3rd %
97th %
Hyperpigmentation
Hypospadias
Hemihypertrophy
Hypopigmentation
Cryptorchidism
Other: _______________________
Other: _______________________
Other: _______________________
Prenatal and Perinatal History
Oligohydramnios
Polyhydramnios
IUGR
Premature birth
Fetal structural abnormality
Fetal soft markers in obstetric ultrasound (Specify below)
Other: __________________________________________________________________________________________
Family History
Parents with greater than or equal to 3 miscarriages
Consanguinity
List health conditions found in family (describe the relationship with proband)
MICROARRAY TEST REQUISITION
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