Genetic Disorder Checklist
Patient Information
Name:
Date of Birth:
Medical Record #:
Genetic Disorder Screening
Family history of genetic disorders
Physical symptoms present
Consanguinity (parents related)
Previous genetic testing performed
Developmental delay
Intellectual disability
Dysmorphic features
Multiple congenital anomalies
Recurrent miscarriages in family
Suspected Disorders
Cystic Fibrosis
Sickle Cell Anemia
Thalassemia
Down Syndrome
Muscular Dystrophy
Hemophilia
Phenylketonuria (PKU)
Tay-Sachs Disease
Additional Notes: