PIEDMONT OBSTETRICS AND GYNECOLOGY

PRENATAL GENETIC SCREENING QUESTIONNAIRE

 

Patients Name_______________________________      Med Rec #__________________

1.  Will you be 35 or older at your due date? yes no -------
2. Are you or the baby's father from Italian, Greek, Middle Eastern, Asian, or Indian (Asian) background?  

If yes, were you or baby's father ever tested for thalassemia or other hemoglobin abnormality?

     yes       no not sure
yes no not sure
3. Have you or the baby's father, or any relatives had a neural tube defect such as open spine, spina bifida or anencephaly? yes no not sure
4.Have you or the baby's father, or any relatives been born with with a heart defect yes no not sure
5.Have you or the baby's father, or any relatives had a pregnancy or child diagnosed with Down Syndrome? yes no not sure
6.Are you or the baby's father of Jewish or French Canadian or Cajun background?

If yes, have you or the baby's father been tested for Tay Sachs disease?

 yes no not sure
yes no not sure
7. Are you or the baby's father of African American descent?

If yes, have you or the baby's father been tested for sickle cell disease/trait?

 yes no not sure
yes no not sure
8. Have you or the baby's father, or any relatives been diagnosed with hemophilia or any other bleeding disorder? yes no not sure
9. Have you or the baby's father, or any relatives been diagnosed with muscular dystrophy or other neuromuscular disease? yes no not sure
10. Have you or the baby's father, or any relatives been diagnosed with cystic fibrosis? yes no not sure
11. Have you or the baby's father, or any relatives with mental retardation, autism or Fragile X? yes no not sure
12. Have you or the baby's father had a stillborn child or two or more pregnancy losses in the past? yes no not sure
13. Have you or the baby's father, or any relatives had a history of Huntington's disease? yes no not sure
14.  Do you or the baby's father or any relatives have a birth defect not listed above? yes no not sure
     If so please describe/name the diagnosis and state who in the family is involved: 

 

I have answered all of the above truthfully and to the best of my knowledge:

Signature_______________________________________  Date _________________

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