Patient registration and clinical history form
Paper or PDF intake form. Fields match the Tribro-Omics phenotype module, so the form can be typed in without re-coding.
1. Registration
Hospital / institution ID
Study / cohort ID
First name
Last name
Date of birth (DD/MM/YYYY)
Biological sex: ☐ Female ☐ Male ☐ Intersex ☐ Unknown
Gender identity (optional)
Ancestry (optional)
Country
City / region
Phone
Email
Referring physician
Clinical geneticist
Primary clinician
Registration date
Case type: ☐ Adult ☐ Paediatric ☐ Neonatal ☐ Prenatal ☐ Deceased Family ID (if family study): ____________
Referral indication
2. Presenting complaints
| Complaint (primary first) | Age / date of onset | Duration | Course | Severity | Source |
|---|---|---|---|---|---|
Course: stable / progressive / improving / episodic / resolved. Source: clinician / patient / caregiver / medical record / test.
3. Medical history
Previous diseases and chronic conditions
Hospitalisations and surgeries
Previous diagnoses and previous genetic testing (test, laboratory, result)
Allergies and adverse drug reactions
| Medication | Dose | Start | Stop | Response |
|---|---|---|---|---|
4. Birth and developmental history
Gestational age (weeks)
Delivery type
Birth weight (g)
Birth length (cm)
Head circumference (cm)
APGAR 1 min / 5 min
NICU admission: ☐ Yes ☐ No ☐ Unknown
Sat unsupported (months)
Walked (months)
First words (months)
Pregnancy history and maternal complications
Neonatal complications and congenital abnormalities
Developmental regression: ☐ Yes ☐ No ☐ Unknown
Intellectual, speech / language, motor and behavioural development
5. Completed by
Name
Role
Date
Signature
© Tribro-Omics · Patient registration and clinical history form · Version 1.0 · 11 November 2026