Genetics Clinic Adult Questionnaire

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:

Joint Hypermobility (joints are highly flexible)	Aneurysm or dissection
Joint pain/arthritis	Low Blood Pressure
Joint dislocation or subluxation	Frequent dizzines, fainting, or near fainting
Retinal or lens detachment	Frequent nosebleeds
Scoliosis	Depression
Chronic Migraines	Anxiety
Chronic Fatigue	Hearing Loss
Abnormal scarring or spontaneous skin tearing	Cancer/non-cancerous tumors
Easy Bruising	Chronic Bowel Issues
Chiari Malformation
Fragile teeth/frequent cavities/crowded teeth/discolored teeth
Surgeries, please describe:
Birth Marks, Skin Changes, Please Describe:
Other Health Concerns:

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)

Are there family members who have learning problems, behavioral issues, birth defects, mental illness, major health concerns, or any known genetic conditions? (Please Explain)
Siblings:
Children:
Parents:
Extended Relatives:

Are there family members with a history of aneurisms, dissections, spontaneous organ rupture, sudden cardiac death, or cardiomyopathy? (Please explain and provide person's age at time of event.)
Siblings:
Children:
Parents:
Extended Relatives:

Are there family members with a history of cancer? (Please note the type of cancer and the person's age at diagnosis')
Siblings:
Children:
Parents:
Extended Relatives:

* If you are a woman who has had children, were there problems during the pregnancy or delivery? Yes No (If yes, please explain.)

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