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Information, Education, Support and Advocacy
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Families, Children, Teens and Adults Who Are Living With The Challenges of
Congenital Anorectal, Colorectal or Urogenital Disorders

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Medical History Information
	Affected individual (check all that apply): self my child other spouse/partner my grandchild
	Name
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	Date Of Birth
	Male Female
	Diagnosis (check all that apply): low imperforate anus anal atresia cloaca bladder exstrophy total colonic Hirschsprung Disease megacolon Down Syndrome Cats-eye Syndrome solitary kidney other renal defects esophageal atresia/TEF caudal regression limb defects tethered spinal cord bifid scrotum other high imperforate anus rectal stenosis cloacal exstrophy short segment Hirschsprung Disease pseudo-obstruction VATER/VACTERL Association Currarino triad Townes Brock Syndrome hydronephrosis neurogenic bladder sacral agenesis scoliosis VSD/ASD hypospadias chordia penis
	Surgeries (check all that apply): colostomy urostomy colectomy PSARP/pullthrough pullthrough re-do prolapse repair sigmoid resection ureter reimplantation MACE or Malone procedure Mitrofanoff other ileostomy vesicostomy anoplasty PSARVUP/cloaca repair ostomy closure tethered cord release adhesions bladder augmentation ACE or cecostomy
	Management (check all that apply): enemas (rectal or antegrade) stool softener diet permanent ileostomy none needed other laxatives anti-diarrhea medication permanent colostomy cath for urine
	Hospital(s) and Doctor(s)