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Amniocentesis Test
Just what is the amniocentesis test and how it can help us diagnose certain conditions during your pregnancy?
 
Who should consider prenatal testing and genetic counseling?
 
  • You are pregnant and will be 35 years of age or older on your due date.
  • You are pregnant with an abnormal expanded AFP blood test. (Quad Test)
  • You have had an ultrasound of your fetus showing a possible birth defect.
  • You have already had a child or close relative with a birth defect or genetic disease.
  • You and your partner are carriers of a recessively inherited disease such as Tay-Sachs, sickle cell anemia, cystic fibrosis or thalassemia.
  • You are a carrier of an X linked disease such as Fragile X, hemophilia or muscular dystrophy.
  • You and your partner are closely related to each other (such as first cousins).
  • You have been exposed to medications, X-rays or other agents during your pregnancy that may be harmful to the developing fetus.
  • To fill out our online assessment form click here

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    Patient Name:
    Physician:
    Occupation:
    Date:
    Home Phone:
    Day Phone:
    Email:
    Age:

    Obstetrical History

    For each of your children, provide as much information as possible
    (Birth Date / Weight / Term or Preterm / Vaginal / Cesarean / Prolonged Pushing / Tearing / Forceps / Complications)
    Pregnancy 1
       
    Pregnancy 2
       
    Pregnancy 3
       
    Pregnancy 4
       
    How many times have you been pregnant?
    How many living children do you have?
    Why did your Doctor Refer you to Prenatal Diagnosis Center?
       

    Medical History

    Please fill in the following History Section: (Check only those that apply)
    Condition Yes Myself Family Member
    Heart Disease:
    Pacemaker
    Lung Problems
    Diabetes
    High Blood Pressure
    Stroke
    Blood Clots
    Low Back Pain
    Pelvic / Abdominal Pain
    Arthritis
    Irritable Bowel Syndrome
    Endometriosis
    Cancer
    Osteoporosis
    Latex Allergy
    Scoliosis
    Visual Impairment Specify
    Thyroid Condition
    Fibromyalgia
    Circulation Disease
    Drug Allergies
    Which Drugs are you allergic to:

    Gender Related History
    Gynecological History

    Please provide information on any of the following that apply to you:
    When was your last menstrual period?
    Do/Did you have pain with your menstrual periods?
    Do/Did you have pain with intercourse?
    Do you have any of the following Yes Myself Family Member
    Endometriosis
    Prolapse
    Cysts
    Pelvic Inflammatory Disease
    Fibroids
    Pelvic Pain
    Other
    GYN Surgeries

    Surgical History
    Back/Neck surgery
    Bladder surgery
    Hysterectomy (Vaginal)
    Hysterectomy (Abdominal)
    Ovaries Removed
    Gall Bladder Surgery
    Appendectomy
    Hernias
    C-Section
    Bowel/Rectal Surgery
    Breast Surgery
    Hemorrhoidectomy
    Other (please specify)

    Medications you are currently using
    Please list medications here

    Social History
    Marital Status
    Ages of Children
    Occupation
    Primary Language
    Do you smoke? If yes how many packs a day and for how many years have you been smoking?
       
       

     
     
    		 
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