Submission of Cases for Opinion
   
  Date of Birth:   
  Age of examination: *   
  Sex: *    Male Female Other
  Presenting complaint:   
  History of present illness:
  (Salient positive and negative history): *		   
  Past history:   
  Antenatal history:   
  Natal history - Birth weight:   
  Development history: *   
   Family history: Consanguineous / non consanguineous parents / other affected siblings: *   
  Examination - General appearance: *   
  Head to foot examination(Please mention the important dysmorphic features): *   
  Weight & centile: *   
  Height & centile: *   
  Head circumference & centile: *   
  System examination: *   
  Investigations: (CBC,LFT/RFT, electrolytes):   
  X rays - Please upload images:    (Maximum file size 2MB)
  USG abdomen:   
  ECHO:   
  MRI brain - Upload image if possible:    (Maximum file size 2MB)
  Other relevant investigations:   
  Any genetic testing done:
  (If yes, give details of the genetic tests done)		   
  Dysmorphic features present:    Yes No
  Clinical photographs: Front profile of face, Side profile of face and any other parts with dysmorphism:    (Maximum file size 2MB)
 * These fields are mandatory  
  Name of the doctor:   
  Affiliation:   
  Email:   
  I confirm that I have taken consent of the patient / parents to share the photographs with other clinicians for opinion purposes
  "NOTE: Please note that this is opinion given on the basis of some images and information about the patient and should not be considered as medical advice. Consulting doctor should be the one to give advice to the patient."
 
   If you encounter any problem with uploading text or image, please contact info@iamg.in