Patient Forms – Pediatric Genetics Questionnaire

Pediatric Genetics Patient Questionnaire

Please complete this form and submit it here, electronically. Once we receive this information, we can then proceed to schedule your/your child's appointment.

Patient Information* After two hours of inactivity, form data will be removed. Patient's Name: * Date of Birth: * Home phone:
Mother's Name: * Date of Birth: * Mother's work phone: Mother's cell phone:
Father's Name: Date of Birth: Father's work phone: Father's cell phone:
Name of person completing this form: Relationship to the patient:

Referral Information Who referred you to see us? What is the reason you have been referred?
Do you have any specific questions that you would like the doctor to address? Please use the space below.

Pregnancy History How many times has the mother of the patient been pregnant? How many children does the mother have (please list by age, sex, and name)?
Do all of the children have the same mother and father? (if no, please explain)
Has the mother had any of the following (please indicate number):
Miscarriages? Please specify: Still births? Please specify: Ectopic (tubal) pregnancies? Please specify: Elective abortions? Please specify:
How old was the patient's mother when the patient was born? How old was the patient's father when the patient was born?

* If you are experiencing difficulties with this form, please contact (714) 288-3500 for assistance. Thank you.

Page 1 of 5