PATIENT REGISTRATION

G E N E R A L PAT I E N T I N F O R M AT I O N

Patient Record Number Patient Record Number in Local Records Date of Birth

yyyy-mm-dd 

Did the parent, guardian or patient (if 18 or older) sign the Patient Record Release Form?

Yes No

Surname/Last Name Given Name/First Name Middle Name

Surname/Last Name (Local Language) Given Name/First Name (Local Language) Middle Name (Local Language)

Gender

Male Female

Race

Asian Caucasian (White) African (Black) Asian (Indian) Hispanic (Latino) Pacific Islander Mixed Other

Street Address Town/Village/City

Country Province District

Zip/Postal Code Phone 1 Phone 2 (Optional)

+1-111-111-1111 or N/A +1-111-111-1111 or N/A

Partner Treatment Center

PA R E N T / G U A R D I A N I N F O R M AT I O N

Surname/Last Name Given Name/First Name

Relationship with patient

Mother Father Grandparent Brother Sister Aunt Uncle Cousin Self Friend Other

How did the patient hear about Smile Train?

Charity Organization Hospital/Physicians Newspaper and TV Internet Friends and Relatives Other

Name of the Referring Organization

FA M I LY H I S T O RY

Length of Pregnancy (months)

Don't know

Did the mother have complications during pregnancy?

Yes No Don't Know

Were there any complications during birth?

Yes No Don't Know

Did the mother smoke during pregnancy?

Yes No Don't Know

Did the mother consume alcohol during pregnancy?

Yes No Don't Know

Do any of the patient's parents and/or siblings brothers/sisters have a cleft lip, cleft palate, or cleft involving the face?

Yes No Don't Know

Do any other relatives (cousins, aunts, uncles, grandparents) have a cleft lip, cleft palate, or cleft involving the face?

Yes No Don't Know

DIAGNOSIS

Evaluation Date

yyyy-mm-dd 
Did the patient have any lip or palate surgery before this evaluation? If yes, pick the type of surgery the Patient had

Yes No
Cleft Lip Surgery

Cleft Palate Surgery

Cleft Lip and Palate Surgery

Diagnosis: (description of lip and palate at birth or before any surgeries)

Lip - Type of Cleft Lip

Patient's Left Patient's Right

Not Cleft Not Cleft

Complete Complete

Incomplete Incomplete

Alveolus - Type of Cleft Lip

Patient's Left Patient's Right

Not Cleft Not Cleft

Complete Complete

Incomplete Incomplete

Hard Palate - Type of Cleft Palate

Patient's Left Patient's Right

Not Cleft Not Cleft

Complete Complete

Incomplete Incomplete

Submucous Submucous

Soft Palate - Type of Cleft Palate

Not Cleft

Complete

Incomplete

Submucous

Additional comments on diagnosis

Additional comments on diagnosis (local language)

Are there additional craniofacial deformities?

Yes No Don't Know

Does this patient have abnormalities in any of the following areas? (check all that may apply)

Heart Ears Tongue Retarded Growth

Yes No Yes No Yes No Yes No

Urinary System Limbs Skull Mental Retardation

Yes No Yes No Yes No Yes No

Eyes Fingers and Toes Mandible

Yes No Yes No Yes No

Nose Skin Speech

Yes No Yes No Yes No

Does patient have allergies?

Yes No Unknown

Other allergies Other allergies (Local Language)

Medication allergies Medication allergies (Local Language)

Other health problems Other health problems (Local Language)