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Tuberous Sclerosis Clinic Pre-Screen Questionnaire

Please complete the questions given. All requested and additional medical records should be sent directly to the Kennedy Krieger Institute. The forms can be emailed to TSClinic@kennedykrieger.org, faxed to (443) 923 - 9540 or mailed to Kennedy Krieger Institute, Emily Thomas, 801 N Broadway 5th Floor Baltimore, MD 21205

Send in the following medical records:

Neurology (Initial evaluation & last 2 visit notes)

Developmental Reports (Cognitive & Language) done within the last 2 years

Images (on CD) and report of EEG (electroencephalogram test) done at anytime

Images (on CD) and report of Brain MRI done at anytime

Report of renal ultrasound done at anytime