Comprehensive DNA Test – Pre-Screen Questionnaire

Comprehensive DNA Test – Pre-Screen Questionnaire
1) Patient details
Name

First NameMiddle InitialLast Name
Phone:
Format: 0000 000 000.
Date of Birth:

DayMonthYear
Date
Gender:
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicare number:
Medicare reference number:
Medicare expiry date:

DayMonthYear
Date
Occupation:
Health Profile Basic Information
Age:
Height (in cm):
Weight (in kg):

Lifestyle
Do you smoke?
How many units of alcohol do you drink per week?
How would you rate your diet?
How many times a week do you exercise?
On average how many minutes do you typically exercise for per session?
Medical History
Enter the date when you checked your blood pressure?
What was your last blood pressure reading?
Please indicate any past medical issues or operations?
List any family medical conditions:
List all medication you take (including natural remedies, supplements, ect)
List any drug allergies you have:
What are your current health concerns and or goals?
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Family Planning (complete if relevant)
Are you currently pregnant or breastfeeding or have you recently given birth?
How many months have you been trying to conceive?
Have you or your partner had any previous fertility tests?
Is there any other relevant information you'd like to share?

Consent to obtain and review pathology
Consent to SMS and email communication
You may withdraw this consent at any time by notifying Peace Health Clinic via Phone, Email or Post.
12) Patient declaration
I declare that the information I have provided is true and complete to the best of my knowledge. I understand that any therapy discussed requires individual assessment, and that I can ask questions and decline treatment at any time.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Should be Empty: