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Приложение № 2

АНКЕТА

Уважаемый коллега!

С целью оказания практической помощи больным с наследственными прогрессирующими мышечными дистрофиями, включая диагностику, лечение, а также профилактику повторных случаев, просим Вас до__________ предоставить сведения о наличии таких больных на Вашем участке (как указано в таблице). Если имеются сомнения относительно достоверности диагноза, то ориентируйтесь на симптомы, перечисленные в анкете 2. Предоставленная информация будет служить основанием для обследования больных в клиниках г. Махачкалы и г. Москвы.

Ф.И.0._________________________________________________________________

Диагноз_______________________________________________________________

Дата рождения___________Пол________Национальность_____________________

Сведения о родителях:

мать (Ф.И.0.)_________________________ Место и дата рожд.____________

отец (Ф.И.О.)_________________________Место и дата рожд.____________

Адрес_________________________________________________________________

Тел. Сот.__________________дом._____________ _email:_____________________

Лечебное учреждение____________________

Врач: Ф.И.0. _______________________тел._______________ email:____________

Формы прогрессирующих мышечных дистрофий, включенных в тестирование:

Лице – плече – лопаточная дистрофия Ландузи-Дежерина Конечностно – поясная прогрессирующая мышечная дистрофия Дистальные миодистрофии Прогрессирующая мышечная дистрофия Эмери-Дрейфуса

Окулофарингеальная прогрессирующая мышечная дистрофия Другие прогрессирующие мышечные дистрофии и миопатические синдромы

Симптомы, указывающие на возможное наличие у больного прогрессирующей мышечной дистрофии Слабость, быстрая утомляемость мышц тазового, плечевого пояса, мимической мускулатуры, глазных мышц

Атрофии или псевдогипертрофии мышц Мышечная гипотония Контрактуры суставов

Гиперлордоз, «крыловидные» лопатки, «осиная» талия Деформации стоп, грудной клетки, позвоночника Неполное смыкание век, глазодвигательные расстройства Нарушение глотания

Нарушение или изменение походки, частые падения, использование вспомогательных приемов при ходьбе, вставании Имеющиеся повторные случаи заболевания в семье, у родственников.

Неуклонно прогрессирующее течение заболевания.

130