Patient Registration Form Page 9

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PATIENT’S NAME:_______________________________________

GENETIC SCREENING

(Includes patient, baby’s father or anyone in either family)

Y/N

Y/N

DOES PATIENT OR FATHER OF

YOUR AGE AT YOUR ESTIMATED

THE BABY HAVE A CHILD WITH

DELIVERY DATE

BIRTH DEFECTS NOT LISTED

THALASSEMIA (ITALIAN, GREEK,

MEDITERRANEAN OR ASIAN) MCV

CYSTIC FIBROSIS

GREATER THAN 80

NEURAL TUBE DEFECT

(MENINGOMYELOCELE, SPINA

HUNTINGTON’S CHOREA

BIFIDA OR ANENCEPHALY)

MENTAL RETARDATION/

CONGENITAL HEART DEFECT

AUTISM (IF YES, HAVE YOU BEEN

TESTED FOR FRAGILE X?)

OTHER GENETIC OR

DOWN SYNDROME

CHROMOSOMAL DISORDER

TAY-SACHS (EG, JEWISH, CAJUN,

MATERNAL METABOLIC

FRENCH CANADIAN)

DISORDER (DIABETES, PKU)

CANAVAN DISEASE

ARE YOU OF JEWISH ANCESTRY

SICKLE CELL DISEASE OR TRAIT

ANY OTHER GENETIC OR

(AFRICAN)

ENVIROMENTAL EXPOSURE?

ARE YOU AND THE FATHER OF

HEMOPHILIA OR OTHER BLOOD

THE BABY RELATED TO EACH

DISORDERS

OTHER? COUSINS?

MUSCULAR DYSTROPHY

OTHER GENETIC HISTORY?

FAMILY MEDICAL HISTORY

CONDITION

YES

DESCRIBE THE PROBLEM AND INCLUDE PERSON’S RELATIONSHIP TO YOU

DIABETES, HIGH CHOLESTEROL, THYROID

DISEASE

HIGH BLOOD PRESSURE, HEART ATTACK,

BLOOD CLOTS, STROKE

TUBERCULOSIS, ASTHMA, OTHER LUNG

DISEASE

BREAST DISEASE, BREAST CANCER

STOMACH, GASTROINTESTINAL, OR COLON

DISEASE OR CANCER

KIDNEY DISEASE, KIDNEY STONES

GYNECOLOGICAL DISEASES, OVARIAN

CANCER , FIBROIDS

MUSCULOSKELETAL DISEASES,

OSTEOPOROSIS

NEUROLOGIC, OR NERVOUS SYSTEM

DISEASE, MIGRAINES

SEVERE DEPRESSION OR OTHER

PSYCHIATRIC CONDITION

GENETIC DISEASE OR BIRTH DEFECTS

LEUKEMIA, LYMPHOMA OR ANY BLOOD OR

BONE MARROW DISEASE

HAS ANY RELATIVE EVER HAD A BONE

MARROW TRANSPLANT

ANY TYPE OF CANCER OR MALIGNANT

TUMORS

OTHER FAMILY HISTORY NOT LISTED

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