Adult Clinical Genetics Follow-up Visit
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:
_________________________________
Interim Medical History:
Since the last visit:
Yes No
Results or Reason
Had an eye exam?
Had a hearing test?
Been in the hospital overnight?
Had surgery?
Been diagnosed with a major medical
condition?
Had any special test or evaluations?
(i.e. CT, MRI, ultrasound, EEG,
ECHO, sleep study, swallow study,
VCUG, X-rays, etc.)
Currently taking any medications?
Please list information about any specialists who have evaluated you since the last visit.
Doctors last
Specialty
Reason for seeing
Date of last Next
name
this doctor
visit
Appointment
Do you 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 Condition/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
Problem
Do you 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 made in therapy (i.e. speech, physical) since the last visit: