___Cataracts. A clouding or opaque area over the lens of the eye--an area that is normally transparent.

___Cleft lip and/or cleft palate. Congenital birth abnormalities that affect one in every 1,000 babies. The abnormalities occur in early pregnancy, when the left and right sides of the lip and roof of the mouth normally fuse together. Cleft lip is a separation in the upper lip. Cleft palate is a separation in the roof of the mouth.

___Congenital heart disease. A condition in which the heart or blood vessels near the heart do not develop normally before birth.

___Contractures. Stiff joints.

___Diaphragmatic hernia. A birth defect in which an opening is present in the diaphragm (the muscle that separates the chest cavity from the abdominal cavity). With this type of birth defect, some of the organs that are normally found in the abdomen move up into the chest cavity through this abnormal opening.

___Genital malformations. Malformations of either the female or male genitals (sex organs).

___Glaucoma. Increased intraocular pressure in the eye that can result in optic nerve damage and loss of sight.

___Misshapen skull

___Missing fingers or toes

___Missing or incomplete arms or legs

___Spina bifida or open spine defects. Neural tube defects in which the neural tube fails to close somewhere along the spine.

___Other problems present at birth:________________

___Bleeding disorders

___Childhood cancers

___Kidney or urinary tract disease

___Slow growth or short stature

___Cystic fibrosis. An inherited autosomal recessive condition that causes the secretion of abnormal mucus in the lungs and problems with pancreas function and food absorption.

___Sickle cell disease. An inherited autosomal recessive condition that causes abnormal hemoglobin in blood cells, leading to infections and organ damage.

___Thalassemia

___Other chronic disease:________

___Autism

___Attention deficit/hyperactivity. A group of symptoms or signs that is usually characterized by serious and persistent difficulties resulting in inattentiveness or "distractibility", impulsivity, and hyperactivity.

___Developmental delay

___Failure to thrive

___Learning disability. A disorder that affects people's ability to either interpret what they see and hear or to link information from different parts of the brain. These limitations can show up in many ways--as specific difficulties with spoken and written language, coordination, self-control, or attention. Such difficulties extend to schoolwork and can impede learning to read or write, or to do math.

___Loss of developmental skills

___Low muscle tone

___Mental illness

___Mental retardation

___Speech problems

___Seizures

___Extreme farsightedness. Also known as hyperopia, farsightedness is the most common refractive error in which an image of a distant object becomes focused behind the retina, either because the eyeball axis is too short, or because the refractive power of the object is too weak. This condition makes close objects appear out of focus and may cause headaches and/or eye strain.

___Extreme nearsightedness. Also known as myopia, nearsightedness is a condition in which, opposite of hyperopia, an image of a distant object becomes focused in front the retina, either because the eyeball axis is too long, or because the refractive power of the object is too strong. This condition makes distant objects appear out of focus and may cause headaches and/or eye strain.

___Hearing loss

___Retinal or other visual problems

___Ear abnormalities

___Unusually shaped eyes

___Different colored eyes

___Facial features that are unusual or are very different from other family members

___Brittle or sparse hair

___Excessive body hair

___White patch(es) of hair

___Large or small tongue

___Misshapen teeth

___Missing or extra teeth

___Loose or stiff joints

___Unusually tall or short stature

___Webbing between fingers or toes

___Excessive skin

___Unusual birthmarks

___Increased or decreased sweating

___Unusual body odor

___Any other unusual features:____________