Clinical Genetics Follow-up Visit
(updated 9/18/12)
Today’s Date: _________
Please complete the following questionnaire as well as you can. Don’t be concerned if you don’t know
some of the answers.
Please list everyone who is attending visit today: _________________________________________
_________________________________________________________________________________
Who lives at home with the child? _____________________________________________________
After your visit, the genetics doctor will dictate and fax a summary of the visit. Please list the
names and fax numbers of EACH of your child’s doctors that you wish to receive the summary.
___________________________________________________________________________________
___________________________________________________________________________________
** Is child currently on formula? __________ Which type? __________________________________
How many ounces?___________________ How often? ______________________________
Interim developmental history:
Have there been any new concerns regarding the child’s development since the last visit?
____________________________________________________________________________________
Please describe any new developmental skills the child has learned since the last visit (i.e. walking now,
talking in sentences, rides a bike):_________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
Has the child lost any skills or abilities since the last visit?  No
 Yes
If yes, describe _______________________________________________________________________
Please provide information about the child’s last developmental evaluation or IQ/developmental testing:
Date
Where? (DEI, school, Doctor’s office, FDLRs, etc.)
Results of testing:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
School information:
Child’s school or Daycare: ____________________________________ Grade: ___________
Does your child attend special classes or receive special help?
 Yes
 No
If yes, specify:________________________________________________________________________
____________________________________________________________________________________
Are there any behavior problems?
 Yes
 No
Describe ___________________________________________________________________________
Does the child receive:
Physical therapy services?
 Yes
 No How often? _____________________
Occupational therapy services?
 Yes
 No How often? _____________________
Speech therapy services?
 Yes
 No How often? _____________________
Please describe any progress the child has made in therapy (i.e. speech, physical) since the last visit:
____________________________________________________________________________________
____________________________________________________________________________________
Interim medical history:
Since the last visit, has your child:
Yes
No
Results or Reason?
Had an eye examination?
Had a hearing test?
Been in the hospital overnight?
Had surgery?
Been diagnosed with a major medical
condition?
Had any special tests or evaluations?
(i.e. CT, MRI, ultrasound, EEG, ECHO,
sleep study, swallow study, VCUG,
X-rays, etc.)
Currently taking any medicines?
Please list information about any specialists who have evaluated your child since the last visit:
Doctor’s last
Specialty (i.e. neurology,
name
GI, ENT, eye doctor, etc)
Reason or problem for seeing this doctor:
Date of last
Next
visit:
Appointment:
Does your child currently have any complaints regarding:
Yes
No
Please list
Eating, sleeping, growth
Eyes
Ears, nose, throat, & mouth
Lungs/Chest
Heart
Stomach, intestines, bowels
Kidneys, bladder, genitals
Muscles, bones, spine, chest
Skin
Neurological system
Psychological/behavior problems
Hormone problems or diabetes
Blood conditions/sickle cell disease
Allergies, immune system
Family history Update:
Are you currently pregnant?________ or planning to have more children?_________________________
Please describe any changes in the family (i.e. births, deaths, illnesses, serious medical problems, birth
defects) that are new since the last visit:
Name
Relation to child
Problem______________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________