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)

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