Genetic Counseling Intake Form
Form preview
This genetic counseling intake form streamlines the collection of detailed family medical history, ethnic background, and specific concerns related to hereditary conditions. The form captures comprehensive pedigree information across multiple generations, previous genetic testing results, pregnancy history when applicable, and the patient's understanding of genetic risks. It includes sections for cancer family history, developmental disorders, and consanguinity assessment.
Ideal for medical genetics practices, prenatal diagnostic centers, cancer genetic counseling services, and specialty clinics offering hereditary disease screening. The form helps genetic counselors prepare detailed pedigrees before appointments, identify appropriate testing strategies, and assess patient education needs. It covers reproductive history, exposure factors, and specific concerns about conditions like BRCA mutations, Lynch syndrome, or chromosomal abnormalities.
What's included
- Patient demographics and contact information
- Detailed three-generation family history
- Ethnic and ancestral background
- Previous genetic testing results
- Pregnancy and reproductive history
- Cancer family history assessment
- Developmental disorders screening
- Consanguinity information
- Specific genetic concerns
- Insurance and referral information
Who uses this template
- Genetic Counseling Clinics
- Prenatal Diagnostic Centers
- Cancer Genetics Programs
- Pediatric Genetics Services
- Reproductive Medicine Clinics
All form fields
8 fields across 3 pages. Customize any field after signing up.
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