Family History Questionnaire Form for Genetic Counseling

Patient Information:

Patient Name:
("Affected" individual)
Date of Birth:
Age:
Place of Birth:
Gender:
Ethnicity:
Mobile:
Phone:
Email:
Marital Status:
No. of
Pregnancies:
Miscarriages
Stillbirths
       
Medical History (any identified genetic condition/ any other illnesses / medications):
Any previous genetic testing done (if 'yes', please mention the test name, result and lab that the test was done from):

Family Information:

Mother Name:
Any other given names:
Date of Birth:
No. of
Pregnancies:
Miscarriages
Stillbirths
       
Medical History (any identified genetic condition/ any other illnesses / medications):
Father's Name:
Date of Birth:
       
Medical History (any identified genetic condition/ any other illnesses / medications):

Sibling

Gender:
Date of Birth:
       
Medical History (any identified genetic condition/ any other illnesses / medications):
Gender:
Date of Birth:
       
Medical History (any identified genetic condition/ any other illnesses / medications):
Gender:
Date of Birth:
       
Medical History (any identified genetic condition/ any other illnesses / medications):

Paternal Grandparents:

Grandfather's Name:
Date of Birth:
       
Medical History (any identified genetic condition/ any other illnesses / medications):
Grandmother Name:
Any other given names:
Date of Birth:
No. of
Pregnancies:
Miscarriages
Stillbirths
       
Medical History (any identified genetic condition/ any other illnesses / medications):

Maternal Grandparents

Grandfather's Name:
Date of Birth:
       
Medical History (any identified genetic condition/ any other illnesses / medications):
Grandmother Name:
Any other given names:
Date of Birth:
No. of
Pregnancies:
Miscarriages
Stillbirths
       
Medical History (any identified genetic condition/ any other illnesses / medications):

Patient's Enquiry:

Any particular questions you would like answered during the genetic counseling session:
   
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Once the filled questionnaire is received, you will be contacted for any more required documents or reports