Filling our and printing this form prior to an appointment with a geneticist or genetic counselor would be helpful for the specialist.

Family and Patient History
Does your family or the father of the baby's family have the following ethnic background:

Yes    No
   Southeast Asia, Taiwan, China, or the Phillippines
   Italy, Greece, or the Middle East

If yes to the previous two questions, have you or your partner been tested for thalassemia? Yes No

Yes    No
   Eastern European (Ashkenazi) Jewish
   French Canadian

If yes to the previous two questions, have you or your partner been tested for Tay Sachs? Yes No

Yes    No
   African American, African, or Black

If yes to the previous question, have you or your partner been tested for sickle cell anemia? Yes No

Have you, the baby's father, or anyone in either of your families ever had any of the following?
If "yes", please explain at the bottom in the space provided:

Yes    No
   Down Syndrome
   Other Chromosome Abnormalities
   Neural Tube Defect (e.g. spina bifida, anencephaly)
   Hemophelia or Other Bleeding Disorders
   Cystic Fibrosis
   Sickle Cell Anemia
   Thalassemia(Mediterranean anemia)
   Tay Sach's Disease
   Muscular Dystrophy
   Neurofibromatosis
   Huntington's Disease
   Other Nerve, Muscle or Seizure Disorder (e.g. epilepsy)
   Phenylketonuria (PKU)
   Kidney Disease
   Heart Defect (from birth)
   Cleft Lip and/or Cleft Palate
   Limb Defects (extra or missing digits, malformed arms, legs, hands or feet)
   Deafness / Early Onset Hearing Loss
   Blindness / Early Onset Vision Loss
   Diabetes
   Cancer before age 50
   Heart Attack before age 40
   Do you or the baby's father have any relatives with mental retardation or
               developmental delay?
   Does anyone in either of your families have a genetic defect, or chromosome
               abnormality not listed above?
   Have you or the baby's father had a baby that died shortly after birth or in the first year?
   Have you or the baby's father had a stilborn child, or three or more first
                trimester miscarriages?
   Are you and the baby's father blood-related in any way (i.e., cousins, uncle-niece, etc.)?
   Is there any other family history that you have concerns about?

Pregnancy History
During this pregnancy, have you had any of the following?
If "yes", please describe, including dates, if known, in the space provided at the bottom:

Yes   No
   Uterine cramping, vaginal bleeding (spotting) or vaginal leakage of fluid
   Infections, rashes, or other illness, fever over 101 degrees
   X-rays, hospitalizations, or surgery
   Cigarettes, alcoholic beverages, or "street" drugs
   Ultrasound ("sonogram")
   Occupational, chemical, or other exposures
   Prescription or non-prescription medications
   Prenatal vitamins

Comments from above

My signature below indicates that the above family and pregnancy history information
provided is complete and correct.

Signature of person completing form                                                                           Today's date

For office use only

G P Sab Tab St.Bth. Ectopic Other
LMP Wks. Gestation EDC

Plan/Indications:

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Geneticist/Genetic Counselor