Informed Consent |
Date |
Type |
Assent |
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Demographics |
Date of Birth |
Biological Gender |
Ethnicity |
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XLH-Specific Medication (All XLH-specific medications, including pain medication) |
Dose |
Compliance |
Duration of Treatment |
Reason for Discontinuation |
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Drug History |
Dose |
Compliance |
Duration of Treatment |
Reason for Discontinuation |
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Radiography and Imaging |
Any radiological assessment of disease severity |
Type of assessment |
Scanner type |
Analysis software used |
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Physical examination |
Age |
Disease-specific examination |
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Vital Signs |
Temperature |
Blood Pressure (Sitting) |
Pulse Rate |
Respiratory Rate |
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Growth Assessments |
Standing Height (metres) |
Sitting Height (metres) |
Arm Length (metres) |
Leg Length (metres) |
Weight (Kg) |
Body Mass Index (BMI) |
Z-scores (based on national reference) |
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Biochemistry |
1,25(OH)2D |
25(OH)2D |
Alanine aminotransferase (ALT) |
Aspartate aminotransferase (AST) |
Amylase |
Bilirubin (direct and total) |
Blood urea nitrogen (BUN) |
Calcium (total) |
Chloride |
Carbon dioxide (CO2) |
Cholesterol (total) |
Creatinine |
Gamma-glutamyl transpeptidase (GGT) |
FGF23 |
Uric acid |
Biochemistry (continued) |
Intact parathyroid hormone (iPTH |
Lactate dehydrogenase |
Phosphorus |
Potassium |
Protein (albumin and total) |
Sodium |
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Haematology |
Haematocrit |
Haemoglobin |
Platelet count |
Red blood cell (RBC) count |
Mean corpuscular volume (MCV) |
Mean Cell Haematocrit (MCH) |
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Urine |
pH |
Specific gravity |
Protein |
Glucose |
Calcium |
Calcium/creatinine ratio |
Phosphorus |
Phosphorus/creatinine ratio |
TmP/GFR |
TRP |
Pregnancy test (if applicable) |
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Physiotherapy Reports |
Number of Visits (since last visit) |
Use of a Wheelchair |
Use of Walking Aids |
Use of Medical Devices |
Home Adaptations |
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Echocardiogram Reports |
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Electrocardiogram Reports |
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Audiology Assessment |
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Renal Ultrasound Scan |
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Assessment Tools/Outcome Measure Reports |
Six Minute Walk Test (6MWT) |
Timed Up and Go Test (TUG) |
Bruininks-Oseretsky Test of Motor Proficiency Section Edition (BOT-2) |
Dynamometry |
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Patient Quality of Life Questionnaires or Assessment Reports (May include the following, but this is not an exclusive list) |
Patient-Reported Outcomes Measurement Information System (PROMIS) [for children ≥5 years of age] |
Short Form 10 (SF-10) [for children ≥5 years of age] |
Pain: Faces Pain Scale-Revised (FPS-R) [for children ≥5 years of age] |
Brief Pain Inventory - Short Form [for adult subjects] |
Brief Fatigue Inventory - Short Form [for adult subjects] |
Short Form 36 (SF-36) [for adult subjects) |
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [for adult subjects] |
Abbreviated XLH Resource Utilisation Survey |
Five-level version of the EuroQoL five-dimensional descriptive system (EQ-5D 5 L) [for adult subjects] |
EQ-5D 5 L Proxy [for children < 5 years of age] |
Paediatric Musculoskeletal Functional Health Questionnaire (PODCI-POSNA) |
General Function Score (GFS) |
Health Assessment Questionnaire (HAQ) |
Patient Index Data 3 (RAPID3) |
Patient Pain Diary |
Social History |
Number of Work/School Dates Missed due to XLH-related Illness since last visit. |
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XLH-Specific Medical, Surgical and Dental History |
Age of Onset of Symptoms |
Age at Diagnosis |
Diagnosis Method(s) |
PHEX Mutation |
Family History |
Changes to XLH-specific history |
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General Medical History |
Pregnancy and Foetal Outcomes |
Gestational/Foetal Exposure to Sponsor Product |
Incidence of Hospitalisations |
Duration of Hospitalisations |
Cause of Hospitalisation |
Date of Death |
Cause of Death |
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