Download PDL Molecular Genetics Patient Information Form

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)
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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.
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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.