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Checklist preliminary evaluation for eventual Fetal Surgery in Zurich
Center for Fetal Diagnosis and Therapy
Prof. Ueli Moehrlen, MD
ueli.moehrlen@kispi.uzh.ch
Prof. Dr. med. Nicole Ochsenbein
nicole.ochsenbein@usz.ch
Coordination / office
University Children’s Hospital Zurich
Steinwiesstrasse 75
8032 Zurich
Phone: +41 44 266 32 28
barbara.casanova@kispi.uzh.ch
montserrat.blazquez@kispi.uzh.ch
www.swissfetus.ch
For whom are you making a request?
For myself
Assignment
First name:
Last name:
E-mail:
Phone:
Maternal evaluation
Last name:
First name:
Date of Birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Unknown (nk)
*
/
*
/
*
(min. 18 years)
Phone home:
Phone work:
Phone mobile:
E-mail:
Home Address:
Postcode
City
Country
Marital status:
Profession/education:
Health insurance:
Case Manager health insurance:
Name
Contact details:
E-mail, Phone no.
Number of pregnancies:
Number of births:
Multiple pregnancy(s):
Yes
No
Weeks:
Days:
Gestational age today (Days):
Prematurity:
Preterm births
Short cervix <20mm
Cervical banding
Pregnancy-associated conditions:
Gestational diabetes
Eclampsia
Maternal-fetal RhesusIsoimmunisation
Kell
Alloimmun Thrombocytopenia
Other
Other pregnancy-related conditions
Uterus-associated conditions:
Myoma
Malformations
Hysterotomy in active uterine segments
Other
Other uterus-associated conditions
Position of placenta:
Anterior
Posterior
Previa
Insertion of umbilical cord:
-- Select option --
Central
Peripheral
Placenta Velamentous
Amount of amniotic fluid:
Normal
Polyhydramnios
Oligohydramnios
Previous surgeries (problems?):
Previous general anesthesias (problems?):
Serious illness:
HIV
Hepatitis
Hypertension
Diabetes
Cardiac disease
Lung disease
Brain disease
Kidney disease
Other
Other serious illness
Body weight:
kg
Body length:
cm
Body Mass Index (BMI):
Psychiatric disorders:
Social problems:
Drugs prescribed by physician:
Smoking:
Yes
No
Alcohol:
Yes
No
Drug consumption:
Yes
No
Fetal evaluation
Lesion
MMC
Myeloschisis
Other
Other lesion
Gibbus
Kyphus
Scoliosis
Other vertebral malformation
vertcond - Additional info
Chiari Malformation II:
Other cerebral deformities:
Ventricular size:
mm
Movement present in:
Hips
Knees
Upper ankle joint
Talipes / clubfeet:
Other deformities
Amniocentesis:
Karyotype
Amniocentesis date
Anmiocentesis status
Planned
Pending
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