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Background Information

Please tick or write your response to these questions concerning background details

Today’s date: 15/11/2017

Please answer the following about the person you care for

Gender

Date of Birth
Age at last birthday

Is the person you care for verbal?

Is the person you care for able to walk unaided

Please answer the following about the person you care for

Has the person you care for been diagnosed with a syndrome

If yes, please indicate which syndrome in 6a. and answer questions 6 to 9. If no, please move on to question 10
Other

What is the genetic mechanism causing the syndrome in the person you care for?
Other

When was the person you care for diagnosed?

Who diagnosed the person you care for?
Other

Please answer the following about the person you care for

Has the person you care for had any medical/health difficulties in the last six months? If yes, please give details

Sometimes it may be needed for us to contact the GP in order to clarify the information regarding your child’s health and diagnostic status. If you are happy for us to do this, please complete the relevant details below:

Name of your child/the person you care for

Address of the GP

Phone number of the GP

Om indholdet af hjemmesiden

Alle oplysninger på dette websted er udelukkende til undervisningsformål. Det er din læge, der er det rette sted at få specifik medicinsk rådgivning, diagnoser og behandling. Brug af dette websted sker udelukkende på eget ansvar. Hvis du finder noget, som du mener, der skal rettes eller præciseres, bedes du give os besked på:

Send en e-mail: wiki@waihonapedia.org

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Background Information

Please answer the following about the person you care for

Please answer the following about the person you care for

Please answer the following about the person you care for

Om indholdet af hjemmesiden

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