Sample Submission Form
Hypertension in childhood and adolescence
Physician
Street Address:
Postal Code:
City:
Country:
Name:
Specialty:
Clinic / Practice:
Phone:
Fax:
Email:
Patient Information
Parents‘ Contact Details
Surname, Given Name(s):
Name(s):
Gender:  male
Street Address:
Postal Code:
City:
Country:
 female
Date of Birth (MM/DD/YYYY):
.
.
Ethnicity (e.g. Italian, Moroccan, Japanese):
Clinical Diagnosis
24-hour ambulatory blood pressure
measurement:
Diagnosis leading to Referral:
Patient’s Age at Diagnosis:
years
months
Blood pressure at Diagnosis:
Date (MM/DD/YYYY):
.
.
I:
/
mmHg
II:
/
mmHg
Earlier documented blood pressure measurements:
Date (MM/DD/YYYY):
.
.
/
mmHg
Date (MM/DD/YYYY):
.
/
mmHg
Current Symptoms:
Phone:
Email:
24-hour average blood pressure:
/
mmHg
Average daytime blood pressure:
/
mmHg
Average nighttime blood pressure:
/
mmHg
Symptoms at Presentation:
Other Diagnoses:
.
Current Medication:
Medication
Dose
Differential Diagnoses:
1
Birth and Infant Development
Gestational Age:
weeks
Perinatal History – Medical Events:
At what age could the patient…
…sit:
months
…crawl:
months
…walk freely:
months
…speak first words:
months
Umbilical Artery Catheter (UAC)?
 ja
 nein
Apgar-Score (if known):
Family History
Are the parents consanguineous?
 yes
 no
If yes, please indicate relationship (e.g. I° cousins).
Are other family members affected by
hypertension?
 yes
 no
If so, who (Name, relationship, age, age of
onset)?
Number of living siblings:
Miscarriages or siblings‘ early deaths?
 yes
 unknown
If yes, please provide details (relationship, age).
Is any of these diseases present in the family?
Which family member(s) is/are affected?




Would they be interested in taking part in
the study?
If so, how can we contact them?
Stroke:
Aneurysm:
Early-onset myocardial infarction:
Early-onset hypertension:
Medical History and Physical Examination
Date:
.
.
unit
Weight:
unit
Size:
BMI:
Blood Pressure
Right arm:
Left arm:
% percentile
% percentile
/
/
mmHg
mmHg
Right leg:
Left leg:
/
/
mmHg
mmHg
2
Other abnormalities:
details:
 aortic coarctation
 developmental delay
 abdominal bruit
 sexual development disorder
 diabetes
 dysmorphic features (e.g. brachydactyly)
 dizziness/imbalance
 haematuria
 hypokalemia
 headache
 excessive consumption of liquorice
 nocturia
 left ventricular hypertrophy
 muscle weakness
 neurofibromatosis
 renal disease
 oedema
 thyroid disease
 sleep apnea
 sweating
 tachycardia
 transplantation (organ)
 other:
 none
Laboratory Evaluation
Haemogram
value
Erythrocytes
unit
reference range
 x 106/µl
 x 1012/l
 g/dl
 mmol/l
%
Haemoglobin
Haematocrit
Leukocytes




Thrombocytes
x 103/µl
x 109/l
/µl
x 109/l
Serum
value
unit
Na+
mmol/l
K+
mmol/l
fasting glucose value
eGFR
 mg/dl
 mmol/l
 mg/dl
 µmol/l
ml/min
BUN
 mg/dl
creatinine
reference range
3
 mmol/l
aldosterone
ng/l
renin
ng/l
plasma renin activity (PRA)
ng/ml/h
cortisol
mg/dl
catecholamines
pg/ml
cholesterol
 mg/dl
 mmol/l
 mg/dl
 mmol/l
triglycerides
Urine
value
unit
reference range
aldosterone
 µg/die
protein
 µg/min
 mg/die
 µg/die
catecholamines
Further Examinations
Cardiology
Has an echocardiography been conducted?
 yes
 no
If yes, please describe results.
Renal biopsy?
 yes
 no
If yes, please describe results.
Nephrology
Renal or renovascular imaging?
 yes
 no
Dexamethasone suppression test?
 yes
 no
If yes, please describe results.
If yes, please describe results.
Colour-coded duplex sonography of the kidney:
Vmax:
m/s
RI right:
RI left:
Genetic Studies
Adrenal imaging?
 yes
 no
Karyotyping?
 yes, details:
 no
Further genetic studies?
If yes, please describe results.
4
Specimen Information
Date obtained (MM/DD/YYYY):
.
.
Sample material:
 Blood
 Saliva
Number of tubes:
Have other family members previously
participated in our study?
 yes
 no
If yes, please provide names.
Please attach the following to your letter:
 This Sample Submission Form
 Specimen tube(s) with names and birth dates. For infants, 1-3 ml blood will be sufficient.
Saliva kits are available upon request.
 Signed informed consent form
 Laboratory evaluation (haemogram, serum electrolytes, urinalysis, creatinine, urea, fasting
glucose, renin, aldosterone, cortisol, catecholamines, triglycerides, cholesterol)
 Additional clinical information (e.g. letters, pedigree)
Thank you very much!
5