Patient History Form

Please carefully read and complete the form to the best of your knowledge at least one week prior to your visit. Additionally, please mail, email or fax any relevant medical records (Mail: 3031 West Grand Blvd. New Center One, Suite 700, Detroit, Michigan 48202; fax to (313) 916-1730 or email to xwang1@hfhs.org) and bring any imaging disks for X-rays, CT scans, MRIs etc. with you to the appointment. Do not hesitate to contact us with any questions at (313) 916-2723.

* Asterisk indicates required field.

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(mm/dd/yyyy Format)
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Medical History
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Has a diagnosis of NF1/NF2/Schwannomatosis been made?


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Please check if the patient has any of the following clinical features













Educational/Occupational History
History of Special Education


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Family History
Do any of the patient's family members have any of the following?