GENETIC FAMILY HISTORY & PREGNANCY QUESTIONNAIRE

GENETIC FAMILY HISTORY
& PREGNANCY QUESTIONNAIRE

Section 1.
Patient Information

Date of Appointment:
Name:
Age:
Date of Birth:
Address:
City:
State:
Zip:
Home phone:
Work phone:
Occupation:
Referring Physician's Name
Referring Physician's Phone Number

Section 2.
Father of the Pregnancy Information

Father's Name:
Father's Date of Birth:
Father's Occupation:

The following questions will help your genetic counselor evaluate the health of your unborn baby and determine if certain tests are appropriate. If you are unsure about your family history, please speak with family members.

Section 3.
Are you or the father of the pregnancy from any of these ethnic backgrounds?

Please check all that apply	Patient	Father of pregnancy
Chinese, Asian Indian, Taiwanese, Filipino, Korean or Southeast Asian
Italian, Greek, Middle Eastern or Spanish
Jewish, French Canadian or Cajun
African American, African Descent, Puerto Rican, Carribean or Black
Hispanic, Mexican, Central American
Caucasian
Other (specify)

Section 4.
Have you, the father of the pregnancy, or anyone in your families
ever had any of the following conditions:

Please choose either yes or no to each of the following:
down syndrome	Yes No
other chromosome problem	Yes No
mental retardation or autism	Yes No
spina bifida (open spine)	Yes No
anencephaly (opening in head/brain)	Yes No
blood disorder, such as hemophilia or sickle cell	Yes No
muscular dystrophy or neuromuscular disease	Yes No
cystic fibrosis	Yes No
neurofibromatosis	Yes No
skeletal disorder, like dwarfism	Yes No
polycystic kidney disease	Yes No
Huntington disease	Yes No
heart defect at birth	Yes No
cleft lip/cleft palate	Yes No
blindness / deafness	Yes No
baby who died after birth or within first year	Yes No
stillborn or 2 or more pregnancy losses	Yes No
any birth defect not listed above	Yes No
any other inherited (genetic) condition	Yes No
any other serious medical condition or surgery	Yes No
Are you or the father of the pregnancy adopted?	Yes No
Are you and the father of the pregnancy related to each other - other than by marriage?	Yes No
Is there a history of infertility in you or father of the pregnancy?	Yes No
Was an egg donor or donor sperm used for this pregnancy?	Yes No
Have you had preimplantation genetic diagnosis (PGD) ?	Yes No
Have you had intracytoplasmic sperm injection (ICSI)?	Yes No

Section 5.
If you are currently pregnant, please complete the following information:

Due Date:
	Yes
medications (other than prenatal vitamins and iron).		if yes, please specify:
recreational drugs
alcoholic drinks
exposure to X-rays
cigarette smoking
rashes, infectious diseases or fevers
spotting, bleeding or any other complications
diabetes, PKU or lupus
a multiple marker blood screening test (AFP blood screen, triple marker screen, maternal serum screen, AFP3, AFP4, etc)		if yes, date of blood test