Genetic Consultation Questionnaire

1 / 9 Personal data

Name and surname:

Date of birth:

Age:

Health insurance company:

E-mail:

Phone:

Occupation (type of school for children):

Occupational health risks (chemicals, radiation):

no

yes

what type:

2 / 9 Personal History – section common to both adult and paediatric patiens

3 / 9 Personal history – section for females and girls only

4 / 9 Personal History - Pregnancy

5 / 9 Personal History - section for males only

6 / 9 Personal History – section for paediatric patients

from which pregnancy:

please specify:

without complications

high-risk pregnancy

birth length (cm):

birth weight (g):

postpartum complications:

no

yes

please specify:

any congenital defects:

no

yes

please specify:

Height (cm):

Weight (kg):

7 / 9 Family History

Please fill in details about all your family relatives, incl. healthy ones (in particular, please indicate oncological diseases, other serious diseases or congenital developmental defects)

Parents

Mother's name and surname:

year of birth:

type of disease:

at age:

age at death:

Father's name and surname:

year of birth:

type of disease:

at age:

age at death:

Mother's family

Mother's mother - name and surname:

year of birth:

type of disease:

at age:

age at death:

Mother's father - name and surname:

year of birth:

type of disease:

at age:

age at death:

Mother's siblings - name and surname:

year of birth:

type of disease:

at age:

age at death:

Mother's siblings - name and surname:

year of birth:

type of disease:

at age:

age at death:

Mother's siblings - name and surname:

year of birth:

type of disease:

at age:

age at death:

Father's family

Father's mother – name and surname:

year of birth:

type of disease:

at age:

age at death:

Father's father – name and surname:

year of birth:

type of disease:

at age:

age at death:

Father's siblings – name and surname:

year of birth:

type of disease:

at age:

age at death:

Father's siblings – name and surname:

year of birth:

type of disease:

at age:

age at death:

Father's siblings – name and surname:

year of birth:

type of disease:

at age:

age at death:

8 / 9 Family History - Siblings

For half-siblings, indicate whether you have common mother or father.

name and surname:

year of birth:

type of disease:

at age:

age at death:

name and surname:

year of birth:

type of disease:

at age:

age at death:

name and surname:

year of birth:

type of disease:

at age:

age at death:

name and surname:

year of birth:

type of disease:

at age:

age at death:

9 / 9 Family History - Children

name and surname:

year of birth:

type of disease:

at age:

age at death:

name and surname:

year of birth:

type of disease:

at age:

age at death:

name and surname:

year of birth:

type of disease:

at age:

age at death:

name and surname:

year of birth:

type of disease:

at age:

age at death:

name and surname:

year of birth:

type of disease:

at age:

age at death:

Any serious illness in another relative in your family?:

no

yes, please specify the relative and type of illness

name and surname:

year of birth:

familial relationship:

type of disease:

at age:

age at death:

name and surname:

year of birth:

familial relationship:

type of disease:

at age:

age at death:

Date of completion:

Name and surname of the legal guardian:

Relationship to the examined person:

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