Appendix A: Assessment and diagnosis of FASD among adults: a national and international systematic review – FAS screening form

Appendix A: FAS screening form

Source: Burd, Cox, Fjelstad, & McCulloch, 1999 as presented in Burd et al. (2003, p. 687)

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Appendix A: FAS screening form (PDF document - 65.79 KB - 2 pages)

Text equivalent: FAS screening form

  • Name_DOB_/_/_Age_
    Sex (circle one) F M
  • Date of Exam_/_/_
  • Child’s Race (circle one) 1) white 2) NA 3) other
  • Height _inches  –5% Y_ N_10
  • Weight_pounds –5% Y_ N_ 10
  • Head Cir._ cm –5% Y_ N_ 10

Head and face

  • Ears stick out (protruding auricles) Y_ N _ 4
  • Skin folds near inner eye (epicanthal folds) Y_ N_5
  • Drooping of eyelids (ptosis) Y_ N _4
  • Crossed eyes – one or both eyes (strabismus) Y_ N _ 3
  • Flat midface/cheeks (hypoplastic macila) Y_ N _ 7
  • Flat/low nose between eyes (low nasal bridge) Y_ N_ 2
  • Upturned nose Y_ N_ 5`
  • Groove between lip and nose absent or shallow (flat philtrum Y_ N _ 5
  • Thin upper lip Y_ N_ 4
  • Cleft lip or cleft of roof of mouth (present or repaired) Y_ N _ 4

Neck and back

  • Short, broad neck Y_ N_ 4
  • Curvature of the spine (scoliosis) Y_ N _ 1
  • Spina bifida (history of neural tube defect) Y_ N _

Arms and hands

  • Fingers, elbows (limited joint mobility) Y_ N_ 4
  • Permanently curved, small fingers, especially pinkies (clinomicrodactuly) Y_ N _ 1
  • Deep or accentuated palmar crease Y_ N _ 4
  • Small nails/nail beds (hypoplatic nails) Y_N_ 1
  • Tremulous, poor finger agility (fine motor dysfunction) Y_ N_ 1

Chest

  • Sunken chest (pectus excavatum) Y_ N _ 3
  • Chest sticks out (pectus carinatum) Y_ N _ 1
  • History of hear murmur or any heart defect Y_ N_ 4

Skin

  • Raised red birthmarks (capillary hemangiomas) Y_ N _ 4
  • Greater than normal body hair, hair also on forehead
    and back (hirsutism) Y_ N _ 1

Development

  • Mild to moderate mental retardation (– 70) Y_ N _ 10
  • Speech and language delays Y_ N _ 2
  • Hearing problems Y_ N_ 1
  • Vision problems Y_ N_1
  • Attention concentration problems Y_ N_2
  • Hyperactivity Y_ N _5

Comments:_

Score total_

Refer if 20 or above

Assessment and Diagnosis of FASD Among Adults: A National and International Systematic Review
Inventory of Literature on the Assessment and Diagnosis of FASD Among Adults

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