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:
* Height: Feet Inches
* Phone: ( )
Person Filling Out Form: (Check if Email and Phone Number are same as patient)
* Relationship to Patient:
* Phone: ( )
* Primary Physician: Phone: ( )
Who Referred You? (Check if Same as Primary Physician)
* Referral Name:
Phone: ( )
* Main Reason For Visit:
Other Health Problems:
Surgeries, please describe:
Issues with Hearing or Vision:
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:
* Previous Genetic Testing? Yes No (If yes, please specify test and results.)
Any Other Testing we should know about?
At what approximate age did the child meet these milestones?
* Hold Up Head:
* Roll Over:
*Say First Word:
Has the child been diagnosed with any of the following?
Speech Delay Developmental Delay Learning Disability Autism
* Does the child receive special services (i.e. special education, resource, speech or physical therapy, counseling)?
Yes No (If yes, please specify)
* Are there concerns regarding intellect, growth, or development? Yes No (If yes, please specify.)
* Are there concerns regarding behavior? Yes No (If yes, please specify.)
* Were there complications? Yes No Unknown (If yes, please specify.)
* Gestational Age:
* Birth Length:
Problems in the newborn period:
* Age of mother at child's birth:
* Age of father at child's birth:
Exposures During Pregnancy:
Alcohol Tobacco Marijuana Cocaine Crack Methamphetamine
Maternal Issues (Diabetes, illness or high fever, surgery, etc.):
Check if you would like to receive a copy of this completed questionnaire by email