Adult History Form

Para la versión en español, seleccione el menú desplegable junto a la bandera
Adult History Form

Department of Medical Genetics and Genomic Medicine
Please note that information entered into this form is kept highly confidential and is protected under the New Jersey Genetic Privacy Act (P.L. 1996, c.126 (C. 10:5-43 et al.) Once completed, the form is submitted directly to the Department of Medical Genetic and Genomic Medicine at Saint Peter's University Hospital.

Timely return of this form will greatly assist us in scheduling your appointment. Please be as specific as possible when documenting. You will receive an email confirmation with instructions for your next steps. If there are any issues completing this form, please contact us at 732-339-7481

Introductory Data
If the adult patient is unable to complete this form on their own, please explain why and who to contact. Example: Incapacitated or Ward of State, etc.
Patient's Full Legal Name:*

First NameLast Name
Patient's Date of Birth:*

MonthDayYear
Date
Patient's Current Age:*
Patient's Gender*

MaleFemaleNon-binary/Third GenderPrefer not to answerOther
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell / Mobile Phone Number

Area CodePhone Number
Can a detailed voice message be left on this number?

NoYes
Home Phone Number

Area CodePhone Number
Can a detailed voice message be left on this number?

NoYes
Email*
example@example.com
Patient's Race:
Race is a socially meaningful category of people who share obvious biologically transmitted traits that are considered important.
Patient's mother's ethnic background
Ethnicity means a shared cultural heritage.
Patient's father's ethnic background
Ethnicity means a shared cultural heritage.
Language(s) spoken at home:
Partner's Full Legal Name

First NameLast Name
Partner's Date of Birth:

MonthDayYear
Date
Partner's current age:
How many biological children does the patient have?
List children by full legal name, date of birth and current age. Use the + sign to list each child separately.
Referring Provider who referred the patient for a genetic evaluation:*

PrefixFirst NameLast Name
Referring Provider Address:*

Group name and specialty

Street Address

CityState / Province

Postal / Zip Code
Office Phone Number:*

Area CodePhone Number
Office Fax Number:*

Area CodePhone Number
Reason for referral:*
When did you first notice a concern?
Please upload a photo of the patient if relevant to the reason for this appointment.

Browse Files
photo Cancelof
Please upload any file that is relevant to this appointment (ie. other specialist consult notes, lab results, etc.)

Browse Files
file Cancelof
What is your expectation for this evaluation?
Primary Care Physician (PCP), only if different from your Referring Provider.

PrefixFirst NameLast Name
PCP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Office Phone Number

Area CodePhone Number
PCP Office Fax Number

Area CodePhone Number

Collapse Stopper

Medical Information
If the patient is female, at what age did the menstrual cycle begin:
If the patient is a female, at what age did she begin menopause (if applicable)?
Please list any medical problems or conditions for which the patient had received care or is currently receiving medical care for. Please include the age of onset:
Please list the names of any other physicians the patient has seen and their specialty. Use the + sign to list each one separately.
Please list all surgeries the patient has had, including the hospital they were performed at and the date. Use the + sign to list each separately.
Please list any other hospitalizations the patient has had, excluding those for surgery. Please include the hospital, dates and reason for admission. Use the + sign to list each separately.
Please list any emergency room visits, accidents or trauma that patient has had (excluding visits in which you were admitted). Please include the hospital, dates and reason. Use the + sign to list each separately.
Please list all medications the patient is currently taking, including dosage and the length of time they have been on them. Use the + sign to list each separately.
Please list any allergies the patient has, especially to medications. Use the + sign to list each separately.
Please list any special dietary restrictions or foods that are avoided. Use the + sign to list each separately.

Collapse Stopper

Social History
How many years of school did the patient complete?
If the patient is currently employed, what kind of work is done?
Is the patient a smoker?

No. Never smokedNo. Currently NOT a smoker, but have smoked in the pastYes. Currently smoke
If previously or currently a smoker, how much?
Are the patient's parents or their families related other than through marriage? If so, please describe:

Collapse Stopper

Family History
Medical Conditions

First Degree Relatives include the child, parents or siblings. Second Degree Relatives include grandparents, aunts, uncles and cousins in relation to the patient. It is important to note that for Second Degree Relatives, whether the condition refers to the mother's side (Maternal) versus the father's side (Paternal). Please indicate if the patient or any of their blood relatives have ever had or currently has any of the listed medical conditions, by selecting the appropriate checkboxes. Omit relatives related by marriage or adoption. Select all that apply if the condition exists with multiple family members on both sides. The Additional Note section can be used to free text any further details regarding your selections.
Miscarriages (how many?)
Stillbirths (how many?)
Infant Deaths (less than 1yr old)
Infertility
Seizures, Epliepsy
Cerebral Palsy
Brain Abnormality
Spina Bifida
Hydrocephalus
Microcephaly (small head)
Blindness or Vision Problems
Deafness or Hearing Loss
Cleft Lip or Cleft Palate
Dental Problems (i.e. extra or missing teeth)
Respiratory Problems (i.e. Asthma, etc)
Born with Heart Defect
Hypertension (high blood pressure)
Heart Attack
Stroke
Pyloric Stenosis
Ulcerative Colitis
Kidney Problems (i.e. Cystic Kidney Disease)
Hip Problems
Scoliosis
Club Foot
Short Stature or Dwarfism
Malformed Extremities (ie hands, fingers, feet, toes, club foot, etc)
Arthritis or Joint Problems
Muscular Dystrophy
Muscle Weakness
Multiple Sclerosis
Parkinson's Disease
Birthmarks
Skin Color Differences
Bleeding Problems (Hemophilia)
Sickle Cell Anemia
Thalassemia
Immune Deficiency
Childhood Diabetes
Adult Diabetes
Thyroid Problems
Alzheimer's Disease
Huntington's Disease
Speech Problems
Intellectual or Learning Disability
Autism
Chromosomal Abnormality
Mental Illness (i.e. Depression, Schizophrenia, Bipolar Disorder, etc.)
Alcoholism or Other Drug/Chemical Dependency
Weight Problem (Obesity or Anorexia)
Cancer (Breast, Colon, Ovarian, Prostate, etc.)
Are there any other relatives with medical problems not listed above?
Please list any other information you believe to be relevant to the patient's referral to our office.

Collapse Stopper

Consent and Signature
By signing below, I certify that all information submitted is true to and correct to the best of my knowledge.
Full Legal Name of the patient or legal representative of the patient completing this form.*

First NameLast Name
Signature of patient or legal representative of the patient.*
Relation to patient*
DateTime
Name of interpreter if applicable:

First NameLast Name
Signature of interpreter if applicable:
DateTime
Should be Empty:

Adult History Form

Medical Conditions