Father of the Pregnancy
Name
DOB (00/00/00)
Age
Ethnic Origin / Religion
Occupation
Mother of the Pregnancy
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? If so, please tell us about it in the 'comments' box at the bottom of this form.
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
