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Molecular Genetics Congenital Inherited Diseases Patient Information Sheet The accurate interpretation and reporting of genetic results is contingent upon the reason for referral, clinical information, ethnic background and family history. To provide the best possible service, please supply the information requested below and send paperwork with the specimen and or requisition to the laboratory or return by fax to Pacific Diagnostic Laboratories 805 692-4611 Patient Information Patient Printed Name (Last, First, Middle) Sex Male Birth Date (MM/DD/YYYY) Female Check box (es) below and complete information to indicate who should receive reports Requesting Physician Phone Genetic Counselor Phone Fax Fax Reason for Testing CARRIER SCREEN (Please check appropriate box) Clinically normal individual with no family history of the condition Family history of the condition Spouse has family history of the condition Spouse is a carrier of the condition Anonymous egg or sperm donor Diagnosis or Suspected Diagnosis (Please list all relevant clinical symptoms: ) Ethnic Background – Ethnic background is necessary to provide appropriate interpretation of test results. Please check the appropriate box. This is especially important for Cystic Fibrosis Testing. Northern European Caucasian Mixed European Caucasian Southern European Caucasian Caucasian (Please indicate countries Hispanic Ashkenazi Jewish Asian French Canadian African American Other (Specify) ____________________________ of origin) ___________________________________________________________ Pregnancy Information Is this patient or partner currently pregnant No Family History Are other relatives known to be affected? No Yes Yes If yes, how many weeks gestation? _______________ If yes, indicate their relationship to the patient: Are other relatives known to be a carrier? No Yes If yes, indicate their relationship to the patient: Have other relatives had molecular genetic testing? No Yes If yes, indicate the results (specific mutation(s) identified and the laboratory at which testing was performed.