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:
Cell 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
Japanese or Korean
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
stroke or blood clot at age less than 50	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
Have you and/or your partner had carrier testing for cystic fibrosis or any other genetic disorder?	Yes No
Have you and/or your partner had blood chromosome testing?	Yes No
Have you or your partner (with a previous partner) ever had a miscarriage, stillbirth, or infant death?	Yes No
If yes, how many times?
If yes, how many weeks/months along was/were the pregnancies?
Have you ever had a pregnancy with growth restriction (IUGR)?	Yes No
Have you ever had a baby born small for its age, or that the doctors delivered early because it was small?	Yes No

Section 5.

Are you currently pregnant?	Yes No
Due Date:
If yes, was this pregnancy achieved with IVF?	Yes No
In this pregnancy, have you used or are you considering: Donor egg or donor sperm?	Yes No
If yes, what is the age of donor?
Have you had preimplantation genetic diagnosis (PGD) ?	Yes No
Have you had intracytoplasmic sperm injection (ICSI)?	Yes No
Do you have diabetes, PKU or lupus	Yes No
Since you have been pregnant: Have you taken any medication?	Yes No
if yes, please specify:
Used any recreational drug?	Yes No
Had any alcoholic drinks?	Yes No
Had exposure to any x-rays (other than dental)?	Yes No
Smoked any cigarettes?	Yes No
Had any rashes, infections, fevers?	Yes No
Have you had any of the following: maternal serum screening, AFP blood test, triple marker screen, quad screen, first trimester screen, sequential screen, integrated screen?	Yes No