Genetic Consultation Checklist

Print out this form to help prepare for your visit.

Personal Medical History 

  • Any medical records or test results pertaining to the disease of concern.
  • Reports from pathology departments such as biopsy results and tumor evaluations are very important. Often, reports of diagnostic imaging studies such as X-rays, MRIs, and ultrasounds are helpful.
  • Reports describing the interpretation of any findings are needed.

Family Medical History 

  • Basic details (such as current age and health status, or age at death and cause of death) about all grandparents, great-grandparents, aunts and uncles, cousins, siblings, and nieces and nephews.
  • Country of origin of each of your four grandparents.
    NOTE: After you schedule your appointment, it can be beneficial to discuss your family history with knowledgeable family members. Individuals often learn of diseases in their ancestors or extended relatives only after they discuss their upcoming genetic evaluation with relatives.
  • Documentation of any related diagnoses in family
  • Pathology reports from the hospitals that treated relatives, or their treating physician’s records.
  • Death certificates if they list the cause of death.
    Note: You will need to have permission to obtain this information, either from your relative or from their next of kin if they are deceased. Sometimes your relatives may have copies of these reports that they are willing to share with you. We can also provide Medical Release Forms that authorize the release of this information directly to us. The forms need to be signed by your relatives or their next of kin, and sent to the facility that has the records.
  • Copy of any gene test results for a blood relative.

Physician Contact Information and Screening History 

  • Names and addresses of all of your physicians and approximate dates of your last visit.

Support 

  • We encourage you to bring a family member or friend to your visits with us. Family members can often help to clarify details about the family history. We review a great deal of technical information, and a support person can provide another set of “ears” and additional perspective on the options available to you.
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