Confidential Page 1 of 10 Physical Examination Form

Clinical Genetics Evaluation

General

Today's Date ______

Study ID ______

Participant Name ______

Date of Birth ______

Current Age ______

Weight ______

%tile ______

Height ______

%tile ______

Growth and Development Developmental Delay Growth Retardation Other

Please Explain ______

Facial Measurements

Outer Canthal Distance (A) ______

%tile ______

Inner Canthal Distance (B) ______

%tile ______

Interpupillary Distance (C) ______

%tile ______

Right Palpebral Fissure Length ______

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%tile ______

Left Palpebral Fissure Length ______

%tile ______

Philtrum Length (D) ______

%tile ______

Mouth Width (E) ______

%tile ______

Lateral Facial Measurements

Upper Third ______

Middle Third ______

Lower Third ______

Left Ear Length ______

%tile ______

Right (E)ar Length ______

%tile ______

Head and Skull

Child - Head Circumference ______

Child - %tile ______

Mother - Head Circumference ______

Mother - %tile ______

Father - Head Circumference ______

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Father - %tile ______

Child - Head Length ______

Mother - Head Length ______

Father - Head Length ______

Child - Head Width ______

Mother - Head Width ______

Father - Head Width ______

Child - Cranial Index ______

Mother - Cranial Index ______

Father - Cranial Index ______

Child - Right oblique (Diagonal B) ______

Mother - Right oblique (Diagonal B) ______

Father - Right oblique (Diagonal B) ______

Child - Left oblique (Diagonal A) ______

Mother - Left oblique (Diagonal A) ______

Father - Left oblique (Diagonal A) ______

Child - Asymmetry Index (CVAI) ______

Mother - Asymmetry Index (CVAI) ______

Father - Asymmetry Index (CVAI) ______

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Skull Sutures

Skull Sutures Normal Synostotic

Sagittal Yes No

Coronal L = left R = right B = bilateral

Metopic Yes No

Lambdoidal L = left R = right B = bilateral

Skull Shape

Asymmetry Present Absent

Brachycephaly Present Absent

Acrocephaly Present Absent

Plagiocephaly Present Absent

Trigonocephaly Present Absent

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Scaphocephaly Present Absent

Cloverleaf Skull Present Absent

Other Present Absent

Please Describe ______

Occipital Shape Normal Flat

Anterior Fontanel Normal Large Small Closed

Posterior Fontanel Normal Large Small Closed

Hairline Normal Abnormal

Please describe

______

Hair Normal Abnormal

Explain

______

Chest and Neck

Neck Normal Abnormal

Please Describe

______

Clavicles Normal Abnormal

Please Describe ______

Chest Circumference ______

%tile ______

Internipple Distance ______

%tile ______

Anterior Chest Deformity None Pectus Excavatum Pectus Carinatum Other

Please Describe

______

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Vertebral Column

Vertebral Column Normal Kyposis Lordosis Scoliosis Other abnormalities

Please Describe ______

Lung Examination

Lung Examination Normal Abnormal

Please Describe

______

Cardiovascular Examination

Cardiovascular Examination Normal Abnormal

Please Describe

______

Blood Pressure ______

Heart Rate ______

Abdomen/Genital Examination

Hernia Yes No

Please Describe

______

Organomegaly Yes No

Please Describe

______

Genital Abnormalities Yes No

Please Explain

______

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Extremities

Upper Extremity Normal Abnormal

Please Explain

______

Hand Lengths

Left Hand Length ______

%tile ______

Left Palm Length ______

%tile ______

Left Middle Finger Length ______

%tile ______

Right Hand Length ______

%tile ______

Right Palm Length ______

%tile ______

Right Middle Finger Length ______

%tile ______

Hand Digits Normal Brachydactyly Arachnodactyly Polydactyly Syndactyly Other Abnormalities

Please Describe

______

Dermatogliphics Normal Abnormal

Please Describe ______

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Nails Normal Abnormal

Explain

______

Lower Extremity Normal Abnormal

Please Explain

______

Feet Digits Normal Brachydactyly Arachnodactyly Polydactyly Syndactyly Other Abnormalities

Please Describe

______

Foot Lengths

Left Foot Length ______

%tile ______

Right Foot Length ______

%tile ______

Arch of Foot Normal Pes planus Pes cavus

Joint Mobility Normal Abnormal

Please describe ______

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Body Measurements

Upper / Lower Segment Ratio Normal Abnormal

Please Explain

______

Arm Span / Height Ratio Normal Abnormal

Please Explain

______

Skin

Skin Normal Abnormal

Explain

______

Neurologic Examination

Neurologic Examination Normal Abnormal

Please Describe

______

Final Diagnosis

Isolated Craniosynostosis Yes No

Please Describe ______

Syndromic Craniosynostosis Yes No

Please Specify

______

Other Diagnosis Yes No

Please Describe

______

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Other Findings and Comments

Other Findings

______

Comments

______

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