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Patient Information

Parent/Guardian Information

Presenting Complaints

First symptoms of disease

Age at Diagnosis

Name of Diagnosing Doctor/Facility

Is there a confirmed genetic diagnosis?

Yes No

specify the mutation type (if known):

Family History of DMD or related conditions?

Yes No

Specify relationship(s)

Current Medications

Allergies?

Yes No

Other Medical Conditions (if any):

Functional Abilities

Current Mobility Status

Walks independently
Uses support (e.g., braces, walker)
Uses a wheelchair (part-time/full-time)
Other (specify)

Current Activities of Daily Living (ADLs):

Independent
Needs Assistance (e.g., dressing, bathing)

Clinical and Therapy Information

Therapies Currently Undergoing:

Physiotherapy
Occupational Therapy
Speech Therapy
Other (specify)

Has the patient undergone genetic counseling?

Yes No

Is the patient enrolled in any clinical trials?

Yes No

Consent and Acknowledgment

I, the undersigned, hereby provide consent for the use of the provided information for medical and research purposes related to Duchenne Muscular Dystrophy care and management.

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