Genetic Diseases Form

Have you had a blood transfusion within the past two weeks, a history of hematological malignancy, an allogenic (non-self donor) bone marrow or stem cell transplant before specimen collection?

Yes

No

Have any of your family members ever been diagnosed with any cancer (Breast, Ovarian, Prostate, Pancreatic, Colon or Male breast cancer)?

Yes

No

Have any of your family members ever been diagnosed with any genetic disorder or had a positive genetic test?

Yes

No

Has there ever been a sudden death in your family or have you or a family member ever experienced unexplained fainting, heart disease or chronic Kidney

Yes

No

Do you have an ancestry of Ashkenazi Jewish ( As they have a history of BRCA gene mutation )

Yes

No

Acknowledgements and Certification

I hereby certify that I have read and acknowledged the entire Hospital's Privacy Policy.

I certify that the personal data filled in this form is true, correct and current. In case I fill in on behalf of other persons, I confirm that I have obtained their consent or have a legal right to disclose their personal data to the Hospital.

Consent
I grant my consent to the Hospital to collect, analyze, process, use and disclose my personal data and send me information about products, services, advertisements, or promotional campaigns that will benefit me through all channels I have provided to the hospital.

I do not acknowledge or accept.

I acknowledge and accept.

Health Risk Assessment

Genetic Diseases

Acknowledgements and Certification

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