New Patient Questionnaire

This questionnaire is designed to be completed by new patients prior to an appointment at our clinic. Collecting this information before an appointment will ensure we can adequately prepare for the consultation.

Please complete and submit the form online, or print the PDF and return it to us via fax or email.

Fields marked with an * are required

A PDF version of the New Patient Questionnaire is available here.

Demographic Details
Date of Birth (You)
Date of Birth (Partner)
Adopted (You)
Adopted (Partner)

Medical History
Do you currently smoke?

Family Background. Ethnicity/Ancestry.
What is your family background/ancestry (You)? *
What is your family background/ancestry (Partner)?

Family Health Information
Conditions (You)
Conditions (Partner)

Family Planning
Are you currently pregnant (You)?
Are you currently pregnant (Partner)?
What is the estimated due date (EDD), if known (You)?
What is the estimated due date (EDD), if known (Partner)?
If no, are you planning on starting/extending your family in the future (You)?
If no, are you planning on starting/extending your family in the future (Partner)?
How did you find out about Genetic Clinics Australia?