PUSAT GENOM MANUSIA

HOSPITAL UNIVERSITI SAINS MALAYSIA

Molecular Diagnostic Services

Diagnostic Test Request Form
(Neuromuscular)
SAMPLE TRANSPORTATION PROCEDURES

1) Appoinment/information

Any cases that related to SMA or DMD, please contact Dr.Teguh Haryo Sasongko (09-7676794 /
012 – 9874175) or Assoc. Prof. Dr.Zilfalil Alwi (09-7676531/ 019-9875767)
2) Diagnostic Test Request Form

Please fill-up the Diagnostic Test Request Form to be sent together with the blood samples.
3) Transportation media

Transportation media that will be used is the container/tube that contains anti-coagulant such as
EDTA.
4) Amount samples needed and how to send the samples

Two EDTA containers with 1.5ml whole blood in each tube.

To make sure the samples are in a safe and good condition, please wrap the containers with the
plastic. Attach a Label ‘NON-HAZARDOUS BLOOD SAMPLES FOR RESEARCH PURPOSE ONLY’
The blood samples should be sent to us as soon as possible at room temperature (on working
days) to this address:
En. Chia Boon Hock, Pusat Genom Manusia, Pusat Pengajian Sains Perubatan, Kampus Kesihatan
USM, 16150 Kubang Kerian, Kelantan. Tel: 09-7676794 /6796
PATIENTS PARTICULARS

Name :

Hospital Registration Number :

Date of birth :

Age :

Sex :

Address :

Tel. no (home) :

(office) :

(H.phone) :

Position and number siblings :

Father’s name :

Age :

Mother’s name :

Age :

FAMILY HISTORY
PEDIGREE (PLEASE DESCRIBE AT LEAST 3 GENERATION)

CLINICAL INFORMATION

1. Age and clinical features at 1st presentation:

2. Clinical Features:________________________________________________________________

_________________________________________________________________________________

3. Best current motor ability:

4. Previous hospital admission and reasons:

5. Consanguinity:

6. Dysmorphism and recognizable syndroms if any:

7. Other abnormalities: _____________________________________________________________

PHYSICAL EXAMINATION

1. Tongue fasciculation:

(R) Upper limb (L) Upper limb (R) Lower limb (L) lower limb
2) Tendon reflexes
3) Muscle tone
4) Muscle power
5) Muscle bulk

INVESTIGATIONS DONE

1. MUSLE BIOPSY
Date done: ______
Result:

2. EMG & nerve conduction study

Date done: ______
Result:

3. SERUM CK Level
Date done: ______
Result:

_____________

OTHER RELEVANT INFORMATION

_______________________________________
CLINICAL DIAGNOSIS

_____________________________________________________________________________________

_____________________________________________________________________________________

TEST REQUESTED (Please tick)

SMN1 Deletion Analysis for Spinal Muscular Atrophy

Molecular Analysis of Dystrophin for Duchenne Muscular Dystrophy

REFERRING CLINICIAN

Name: _____________

Address:

Phone no:

Fax no.

FOR OFFICIAL USE:

Sample acceptance date : ________________________________________________________________

Sample Lab No. : _______________________________________________________________________

Sample Quality:

Feasible for DNA Extracttion

Feasible for DNA Extraction with low yield (Cause: _______________________________________)

Not Feasible for DNA Extraction (Cause: _______________________________________________)

Sample accepted by (Name and Cop): ______________________________________________________

_____________________________________________________________________________________

Confirmation to Referring Clinician :

Date/Time: _____________________________________________________________________
By : ___________________________________________________________________________