Genetic Counseling Pre-Visit Questionnaire

Genetic Counseling Pre-Visit Questionnaire — Form Fields

This healthcare template includes 13 fields. Pre-visit questionnaire for patients scheduled for genetic counseling sessions. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Reason for Genetic Counseling (dropdown selection, required) — options: Family Planning, Cancer Risk, Prenatal Testing, Newborn Screening Follow-Up, Known Family Condition, Carrier Testing, Pharmacogenomics
• Ethnicity (for risk assessment) (dropdown selection, optional) — options: European, African, Asian, Hispanic/Latino, Middle Eastern, Ashkenazi Jewish, Mixed, Prefer Not to Say
• Family History of Genetic Conditions (multiple choice, required) — options: Yes, No, Unknown
• Specify Genetic Conditions in Family (text, optional)
• Currently Pregnant (multiple choice, optional) — options: Yes, No, N/A
• Family Members with Cancer (checkboxes, optional) — options: Mother, Father, Sibling, Grandparent, Aunt/Uncle, None
• Family Medical History Details (long text, required)
• Previous Genetic Testing (multiple choice, required) — options: Yes, No
• Previous Test Results (file upload, optional)