Chromosomal Microarray (Array Cgh) Requisition Form (Page 2 of 2) in pdf

Patient label placed here (if applicable) or if labels are

not used, minimum information below is required

Name

(last, ﬁ rst)

Birthdate

(yyyy-Mon-dd)

Chromosomal Microarray (CMA) Requisition

Gender

Cytogenetics Laboratory North: University of Alberta Hospital

PHN #

Cytogenetics Laboratory South: Alberta Children’s Hospital

Address

Phenotypic Description Required

(check all that apply)

Behaviour and Cognition

Respiratory

Musculoskeletal

 Global developmental delay

 Diaphragmatic hernia

 Upper limb abnormality

 Intellectual disability

 Lung abnormality

 Lower limb abnormality

 Mild

 Other

_____________________

 Camptodactyly

 Moderate

 Syndactyly

 Severe

Craniofacial/Dysmorphic features

 Polydactyly

 Speech delay

 Craniosynostosis

 Contractures

 Autism spectrum disorder

 Cleft lip

 Scoliosis

 Other

____________________

 Cleft palate

 Vertebral anomaly

 Other

_____________________

 Club foot

Neurological

____________________________

 Other

_____________________

 Hypotonia

 Seizures

Eye

Genitourinary

 Ataxia

 Blindness

 Urinary tract malformation

 Spasticity

 Coloboma

 Hydronephrosis

 Neural tube defect

 Hypertelorism

 Ambiguous genitalia

 Abnormal MRI/CT

 Other

_____________________

 Hypospadias

 Movement disorder

 Cryptorchidism

Specify

____________________

Ear

 Psychiatric Disorders

 Other

_____________________

 Deafness

Specify

____________________

 Structural outer ear anomaly(ies)

Prenatal

 Other

_____________________

 Other

_____________________

 Oligohydramnios

Growth Parameters

 Polyhydramnios

Cutaneous

 Failure to thrive

 IUGR

Weight for age

 Hyperpigmentation

 Nuchal translucency greater

 less than 3%

 Hypopigmentation

than or equal to 3.5 mm

 greater than 97%

 Other

_____________________

 Other

_____________________

Stature for age

 less than 3%

Gastrointestinal

 greater than 97%

 Esophageal atresia

Other

______________________

Head circumference

 Tracheoesophageal ﬁ stula

____________________________

 less than 3%

 Gastroschisis

____________________________

 greater than 97%

 Omphalocele

 Hemihypertrophy

____________________________

 Pyloric stenosis

 Other

____________________

____________________________

 Other

_____________________

____________________________

Cardiac

____________________________

 ASD

 VSD

____________________________

 AV canal defect

____________________________

 Coarctation of aorta

____________________________

 Tetralogy of Fallot

 Other

_____________________

Page 1 Side B

09591(Rev2015-11)

Chromosomal Microarray (Array Cgh) Requisition Form Page 2

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