Genetic Intake Form
Evaluate Your Genetic Risk
As part of your fertility treatment, it is important that we evaluate your family history to identify any areas of genetic risk. We encourage you to ask your family members about their medical history. The completed form will be reviewed by an ORM genetic counselor. You may be contacted for an appointment if additional questions arise. Please discuss any specific family history concerns during your new patient visit with the physician. For each question below, please check the option. If yes, please explain in the space provided.