New Patient Intake forms

Immunodeficiency Evaluation

Medical Intake
This form will serve as a medical intake, which will allow us to check your eligibility to recieve your immunodeficiency genetic. All your information is confidential and secure. We follow all HIPAA laws and do not share any of your information with anyone outside our organization without prior wriiten consent.
Product

Comprehensive NEURO testComprehensive Cancer testComprehensive Immunodeficiency test
Have you ever taken an at home-cheek swab for genetic testing before?

YESNO
Patient's Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
NAME OF YOUR INSURANCE CARRIER: (IF ONLY MEDICARE, TYPE MEDICARE)*
Medicare ID Number:
Is Medicare your primary insurance?*

YESNO
GENDER:*

MALEFEMALE
Ethnicity:*
What is your height and weight?
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Main Phone Number*
Second Phone Number
Please enter a valid phone number.
Email*
example@example.com
What time is best to reach you?
Texting Consent (May we text reminders for your follow-up appointment?)*

YESNO
Primary Care Provider (first and last name)*
City and State*
Patient Personal History:
PERSONAL History notes: Please list any diagnosis or symptoms you have had.

PERSONAL Medical History: Has a doctor DIAGNOSED you with any of the following immunodeficiency conditions?*

	YES	NO	Age diagnosed?
Type 1 Diabetes
Rheumatoid or Psoriatic Arthritis
Multiple Sclerosis
Lupus
Bone Marrow Failure Syndromes
DiGeorge Syndrome
Chronic inflammatory demyelinating polyneuropathy
Chronic Pneumonia
Chronic bronchitis
Chronic Sinusitis UNSP
Chronic Ear Infections
Meningitis
Skin infections
Crohn’s Disease
Anemia
Hemophilia
LYMPHOMAS (example: Non-Hodgkin Lymphoma)
NONE OF THE ABOVE

PERSONAL Medical History: Has a doctor DIAGNOSED you with any of the following cancer or neurocognitive conditions?

	YES	NO	Age diagnosed?
Dementia
Parkinson’s disease
Alzheimer’s disease
Prostate, breast, ovarian, & pancreatic Cancer
NONE OF THE ABOVE

PERSONAL: Are you suffering from any of the following immunodeficiency SYMPTOMS??*

	YES	NO	Age when it started?
Multiple, unusual, or severe allergies (example: Asthma)
Severe eczema/atopic dermatitis
Ectodermal dysplasia
Abnormal hair (example: Alopecia)
Enteropathy
Autoimmune Lymphoproliferative disease
Digestive problems, such as cramping, loss of appetite, nausea and diarrhea
NONE OF THE ABOVE

PERSONAL: Are you suffering from any of the following neurocogitive SYMPTOMS??

Social History

	Yes	No	Comments
Tobacco Usage History
Alcohol Usage History
Recreational Drug Usage History

Personal Allergies:

	On going	In the Past	Comments
Food allergies
Environmental allergies
Multiple chemical sensitivites
Latex allergy
Pet allergies
other
NONE

FAMILY HISTORY:

Has anyone in your family (parents, grandparents, children, uncle/aunts, niece/nephew, cousins) ever ... ?
Family History notes: Please list any diagnosis your family members have had.

FAMILY Medical History: Has a doctor DIAGNOSED anyone in your family with any of the following immunodeficiency conditions?*

	YES	NO	Family member?
Type 1 Diabetes
Rheumatoid or Psoriatic Arthritis
Multiple Sclerosis
Asthma
Lupus
Bone Marrow Failure Syndromes
DiGeorge Syndrome
Chronic inflammatory demyelinating polyneuropathy
Chronic Pneumonia
Chronic bronchitis
Chronic Sinusitis UNSP
Chronic Ear Infections
Meningitis
Skin infections
Crohn’s Disease
Anemia
Hemophilia
LYMPHOMAS (example: Non-Hodgkin Lymphoma)
NONE OF THE ABOVE

FAMILY Medical History: Has a doctor DIAGNOSED anyone in your family with any of the following cancer or neurocognitive conditions?

	YES	NO	Family member?
Dementia
Parkinson’s disease
Alzheimer’s disease
Prostate, breast, ovarian, & pancreatic Cancer
NONE OF THE ABOVE

Personal Medications

Personal medications List
How many prescription medications are you taking?*
Please list your current prescribed medications?
HC - Atorvastatin (Lipitor®)Fluvastatin (Lescol®)Lovastatin (Mevacor®, Altoprev™)Pravastatin (Pravachol®)Rosuvastatin Calcium (Crestor®)Simvastatin (Zocor®) HBP - benazepril (Lotensin)captopril (Capoten)enalapril (Vasotec)fosinopril (Monopril)lisinopril (Prinivil, Zestril)moexipril (Univasc)perindopril (Aceon)quinapril (Accupril)
OK Great. That's all we needed to gather from you right now. We will turn your file in to our eligibility team to verify the information you provided to make sure this test is for you. If everything comes back good, they will give you a call. ***Eligibility also is dependent on patient’s insurance.***

Please feel free to call us if you have any questions

(888) 505 -3536.
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Immunodeficiency Evaluation