FASD 4-Digit Code Diagnostic Forms    


Two standardized data collection forms are used by the 4-Digit Diagnostic Code.

  1. FASD Diagnostic Form: This form guides the interdisciplinary diagnostic team in the collection, recording, and interpretation of all key information used to derive accurate and precise FASD 4-Digit Diagnostic Codes. This form is fully described and provided in the Diagnostic Guide for FASD (2004). Two pdf versions of this form are also available below (a paper form and an electronic fillable form).

    In lieu of the more comprehensive 7-page FASD Diagnostic Form, some clinics may perfer to use the 1-page FASD 4-Digit Short Form. The Short Form allows a clinician to record the minimum amount of data required to derive/support the 4-Digit Code. Clinical teams who do not have the time/capacity to complete the more comprehensive form will find this Short Form helpful.

  2. New Patient Information Form: This form is sent to families requesting a diagnostic evaluation. The form allows the family to share with the clinic why they are seeking a diagnostic evaluation, what they hope to gain from the evaluation and what they currently know about the patient's exposure(s) and outcomes. This form serves as the clinical intake form. It is fully described and provided in the Appendix of the Diagnostic Guide for FASD (2004). A pdf version of this form is provided below.

Also provided for your review is a sample Medical Summary Report used in the University of Washington FAS Diagnostic & Prevention Network clinic. This report documents the results of the patient's FASD Diagnostic Evaluation and is submitted to the patient's medical record. An important feature of the Medical Summary Report, from both a medical and public health perspective, is the inclusion of all information used to derive/support the FASD 4-Digit Code. We do not submit the FASD Diagnostic Form or the New Patient Information Form to the patient's medical record.

 

FASD Diagnostic Form

FASD 4-Digit Short Form

New Patient Information Form

Sample Medical Summary Form

  • Paper Form - This is an example of the format and content we incorporate into our medical summary to document the results of a patient's FASD diagnostic evaluation. This is an example of just one of several diagnoses that fall under the umbrella of FASD.