Patient Information And Referral Form Page 2
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3MORPHOLOGICAL ABNORMALITIES
Imaging performed ?
MRI
CT
Ultrasonography
Abdomen / Adrenal Glands
Genitourinary Tract
Pituitary
Note: You can send us copies of MRI / CT scans for free evaluation. Especially if
morphological abnormalities are present please enclose a copy.
FAMILY
Please give a pedigree drawing below, sign all affected family members and when
possible give data for height and weight.
= not affected
= affected
Consanguinity of parents:
Yes
No
Unknown
GROWTH CHART
Please enclose a growth chart with indication of bone age and start and stop of
hormone replacement therapy.
HORMONE REPLACEMENT
Please give information about hormone replacement therapy below. For example start,
stop and dose of hydrocortisone.
Johannes FW Weigel and Roland W Pfäffle (2004)
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