Genetic Counseling Intake Form

Genetic Counseling Intake Form — Form Fields

This healthcare template includes 10 fields. Collect family history and personal health information for patients seeking genetic counseling services. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Referring Provider (text, optional)
• Reason for Referral (dropdown selection, required) — options: Hereditary cancer risk, Prenatal screening, Family planning, Inherited heart condition, Neurological condition, Unknown genetic condition, Other
• What prompted you to seek genetic counseling? (long text, required)
• Have you had previous genetic testing? (multiple choice, required) — options: Yes, No, Unsure
• If yes, please describe (text, optional)
• Family History of Genetic Conditions (checkboxes, optional) — options: BRCA1/BRCA2 (breast/ovarian cancer), Lynch syndrome (colon cancer), Huntington disease, Cystic fibrosis, Fragile X, Muscular dystrophy, None known
• Additional family health history (long text, optional)