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 Email and Phone Number are 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:


Birth Defects:

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:

Current Medications:

* Previous Genetic Testing? Yes No   (If yes, please specify test and results.)

Any Other Testing we should know about?

Child's Behavior and Development:

At what approximate age did the child meet these milestones?

* Hold Up Head: * Roll Over: *Sit/Walk:

*Say First Word: *Toilet Trained:

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.)

Pregnancy And Birth History:   (only if the patient is a child)

* Were there complications? Yes No Unknown   (If yes, please specify.)

* Gestational Age: * Birth Length: *Birth Weight:

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.):


Family History:

Child's brothers and sisters (list genders and ages of half and/or full siblings)
Gender Age
Male    Female    Other

Are there learning problems, behavioral issues, birth defects, mental illness, or any known genetic conditions in the child's family'?     (Please Explain)
Extended Relatives:

Other Concerns?

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