It is helpful for us to know the medical history of our patients before scheduling an appointment. Please complete this questionnaire.
A copy of this completed questionnaire and general information about the genetic clinic will be emailed to you if you check the box at the bottom of the questionnaire.
If you have questions regarding this questionnaire, please call 402-559-6418
* Denotes required field
* Patient Name: * Date of Birth: Ethnicity:
* Height: Feet Inches * Weight: * Phone: ( ) Email:
Person Filling Out Form: (Check if Same as Patient)
* Name: * Relationship to Patient:
* Phone: ( ) - Email:
* Primary Physician: Phone: ( ) -
Who Referred You? (Check if Same as Primary Physician)
* Referral Name: Phone: ( ) -
* Main Reason For Visit:
PATIENT'S HEALTH HISTORY:
Mark any of the following symptoms or findings that the patient has now or has had in the past:
Imaging Studies (check if previously done):
MRI/CT Echocardiogram EEG X-rays Abdominal Ultrasound
If you checked any of the above, please explain any abnormal findings:
Current Medications:
* Previous Genetic Testing? Yes No (If yes, please specify test and results.)
* Have any family members had genetic testing? Yes No (If yes, please specify test and results.)
* Does the patient receive special services (i.e. speech or physical therapy, counseling)?
Yes No (If yes, please specify)
* If you are a woman who has had children, were there problems during the pregnancy or delivery? Yes No (If yes, please explain.)
Check if you would like to receive a copy of this completed questionnaire by email