Title Page in APA format
Introduction
Tell what the paper is about
Body of the Paper
Use the criteria in the assignment as headings
.
The Genetic disorder
Remember you are writing about the disease from the genetic perspective, not a medical
surgical condition. Include references. Write scholarly not in slang or like on social media
post
Conclusion
Summarize what the paper was about
References
Appendix A
Genetic Family history form
Date:
Date of Birth:
Sex:
Ethnicity:
Address:
Phone number:
Work number:
Occupation:
Highest Grade Completed:
Name of spouse:
Date of Birth:
Referring doctor:
Address:
Family doctor:
Address:
Reason for Referral:
Medical Diagnosis (if known):
List any Health Problem you (the patient):
List any Hospitalization (Place, Reason & date):
Name and Location
Reason
Date
The Index PatientàBrothers/Sisters and their Children
List your brothers/sister. Please include stillbirths(sb), miscarriage(m), and those
deceased(d).
Name of Sibling
Date of birth
month/year
Sex
Present Health
SiblingÊChildren
List age &
sex
Are any of the above half-brothers/sisters and/or stepbrothers/sisters?
Are any of the above adopted or foster children?
Biological Mother of Index Patient
Name:
Maiden (family) name:
Date and place of birth:
Ethnic origin:
Present health
(if deceased, date and cause of death)
from complications
MotheràBrother and sisters and their Children
deceased at the age of
Include stillbirths(sb), miscarriages(m), deceased(d)
Name of Sibling
Date of birth
month/year
Sex
Present Health
SiblingÊChildren
List age &
sex
Are any of the above half-brothers/sisters and/or stepbrothers/sisters?
Other information of significance:
Maternal Grandfather
Name:
Date and place of birth:
Ethnic origin:
How many brothers?
How many sisters?
Present health (if deceased, date and cause of death)
from complications
deceased at the age of
Maternal Grandmother
Name:
Date and place of birth:
Ethnic origin:
How many brothers?
How many sisters?
Present health
(if deceased, date and cause of death)
from complications
deceased at the age of
Is there anyone else on the maternal side of the family that has any birth defects, mental
retardation, or there any other health concerns not yet mentioned? List each person
affected and identify the problems.
Biological Father of Index Patient
Name:
Maiden (family) name:
Date and place of birth:
Ethnic origin:
Present health
(if deceased, date and cause of death)
from complications
deceased at the age of
FatheràBrother and sisters and their Children
Include stillbirths(sb), miscarriages(m), deceased(d)
Name of Sibling
Date of birth
month/year
Sex
Present Health
SiblingÊChildren
Are any of the above half-brothers/sisters and/or stepbrothers/sisters?
Other information of significance:
Paternal Grandfather
Name:
List age &
sex
Date and place of birth:
Ethnic origin:
How many brothers?
How many sisters?
Present health
(if deceased, date and cause of death)
from complications
deceased at the age of
Paternal Grandmother
Name:
Date and place of birth:
Ethnic origin:
How many brothers?
How many sisters?
Present health
(if deceased, date and cause of death)
from complications
deceased at the age of
Is there anyone else on the paternal side of the family that has any birth defects, mental
retardation, or there any other health concerns not yet mentioned? List each person
affected and identify the problems.

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