Pharmacogenetic (PGx) Test Information Form

Physician Information

Physician Name

Sample collection date:

Ordering Physician Name

PATIENT INFORMATION PERSONAL DATA

Patient Name (Last, First, MI)

Date of Birth (mm/dd/yy):

Heigt

Weight

Address

Phone Number

E-mail

Ethnic Origin

Caucasian

African American

African

Asian

Hispanic

Middle Easter

Other

Gender

Male

Female

If the patient is a woman, fill in the information below.

Menapause

Current pregnancy

Current breast feeding

Current contraceptive treatment

REPORTED CLINICAL FEATURES

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MEDICATION (prescription and over-the-counter medications)

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HERBAL MEDICINES

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VITAMINS AND SUPPLEMENTS

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HORMONE REPLACEMENT THERAPY

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ALLERGIES/ ADVERSE DRUG REACTIONS

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Adverse Drug Reactions (ADRs)

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LIFESTYLE ELEMENTS

Cigarette smoking

Yes

Passive smoker

Yes

Smoker

<15 cigarettes/day

>15 cigarettes/day

1 pack/day

1 Pack/day

Consumption of alcohol

Yes

Consumption of Alcohol Sometimes

Wine

Beer

Other

Consumption of Alcohol Sometimes Regularly

Wine

Beer

Other

Frequency of alcohol consumption

1-2 cups/day

3 cups/day

More than 3 cups/day

1-2 cups/week

3 cups/week

More than 3 cups/week

Consumption of caffeinated beverages (coffee, tea, cola, etc.)

Yes

Consumption of caffeinated beverages Sometimes

Coffe

Tea

Cola

Other

Consumption of caffeinated beverages Regularly

Coffe

Tea

Cola

Other

Caffeine Consumption Frequency

1-2 glasses/day

3 glasses/day

>3 glasses/day

1-2 glasses/w

3 glasses/w

>3 glasses/w

Grapefruit juice consumption

Never

Occasionally

Regularly

if Regulary?

1-2 glasses/day

3 glasses/day

>3 glasses/day

1-2 glasses/w

3 glasses/w

>3 glasses/w

MEDICAL STORY

Weight loss or gain

Yes

High blood pressure problem (ie > 140/90)

Yes

Have you ever had severe episodes of hypoglycemia?

Yes

Have you had an increase in cholesterol, triglycerides?

Yes

DIABETES

Diabetes I

Diabetes 2

Monogenic (MODY)

Have you ever had myocardial infarction (heart attack)

Yes

Do you suffer from heart failure?

Yes

Do you have thrombosis problem?

Yes

Do you suffer from peripheral vascular disease (PVD)?

Yes

Do you have kidney disease problem?

I Have

I Don't Have

Do you have liver disease

I Have

I Don't Have

Gastrointestinal diseases

I don't have

Gastrit

Kolit

Pankreatit

Do you have a cancer?

I Have

I Don't Have

If yes, please specify the type of cancer?

If you have any other chronic illness (or long-term emotional disorder) not listed above, please download it below.

FOR FEMALE INDIVIDUALS ONLY

Endometriosis

I Have

I Don't Have

Osteoporosis

I Have

I Don't Have

INHERITED GENETIC VARIABILITY IN DRUG RESPONSE

Have you ever taken medication with little or no effect?

Yes

Has any family member (father, mother, uncle, aunt, distant cousins "blood relatives", etc.) ever taken medication with little or no effect?

Yes

Have you ever constantly experienced side effects (fatigue, dizziness, headache, diarrhea, constipation, cramps, and/or other rashes) for certain medications?

Yes

Has any family member ever experienced the side effects of certain medications?

Yes

Are you intolerant or insensitive to certain medications such as codeine, beta-blockers, antidepressants and/or others?

Yes

Is any family member (father, mother, uncle, aunt, distant cousins "blood relatives", etc.) intolerant or insensitive to certain medications such as codeine, beta-blockers, antidepressants and/or others?

Yes

Has a family member ever been hospitalized due to medication?

Yes

Has any family member in the hospital ever had side effects from their medications?

Yes

I hereby certify that the information I have provided above is correct. I agree to share the above information with Epigenetic Coaching (MRL Medical Tourism Marketing and Consulting LTD ) with my own consent. While sharing this information, I have read and approved the terms and conditions of MRL Medical Tourism Marketing and Consulting LTD.

I have read and approved the order form.

I have read and approved the Data Protection Policy.

I have read and approved the Nutrigenetic and Epigenetic Consulting Form