Please complete and submit this questionnaire to Albany Medical Center for testing for Gaucher Disease.
Date: (mm/dd/yy)
Date of Birth: (mm/dd/yy) Name: Address: City: State AK AL AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NB NC ND NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: Telephone: Home: Work:
Email:
1. Have you ever been diagnosed with Gaucher disease?
If yes, are you currently receiving treatment?
If yes, where?
2. Have any of your immediate family members been diagnosed with Gaucher disease?
If yes, who?
3. Are you or your family from Jewish ancestry?
4. Are you or your family from Eastern or Central European descent?
5. Have you had or do you currently have any of the following symptoms:
Yes No Don't Know Anemia
Yes No Don't Know Easy Bruising
Yes No Don't Know Easy Bleeding (especially from gums)
Yes No Don't Know Frequent Nose Bleeds
Yes No Don't Know Enlarged Liver
Yes No Don't Know Enlarged Spleen
Unexplained Bone Fractures:
If Yes, where?
Unexplained Bone Pain (especially hip area, lower back):
6. Have you had a recent blood count?
If yes, do you know: Hemoglobin count? Platelet count?
7. Have you been diagnosed with any other disorders?
If yes, what?
8. May we contact your physician to send information?
Please give us your physician's name, address, telephone and fax number:
9. Where did you see the advertisement, brochure, or poster?
Thank you for contacting Albany Medical College. Please be assured that a nurse from the treatment center will get back to you within 10-14 days. If necessary, you will be referred to a health center in your area for a Gaucher test; or you or your doctor will be sent a test kit in the mail.
