Microsoft word - 466e00e5-4fc4-287103.doc

G E N E T I C S C R E E N I N G Q U E S T I O N N A I R E C r e a t e d B y M a r k R a b i n o w i t z C r e a t e d o n 1 1 / 2 2 / 2 0 0 3 9 : 5 4 A M L a s t P r i n t e d o n 1 1 / 2 2 / 2 0 0 3 9 : 5 5 A M THIS FORM IS TO BE FILLED OUT BY THE MOTHER AND THE FATHER OF THE EXPECTED BABY (BIOLOGIC PARENTS) PLACE FOR ‘YES’ IN THE ‘Y’ BOX; PLACE FOR ‘NO’ IN THE ‘N’ BOX WILL THE MOTHER BE AGE 35 OR OLDER WHEN THE BABY IS BORN? AGE OF MOTHER AT EXPECTED DUE DATE __________. Y N HAS THE EXPECTED BABY’S MOTHER OR FATHER OR ANYONE IN EITHER OF YOUR FAMILIES EVER HAD: NEURAL TUBE DEFECT, SPINA BIFIDA, MENINGOMYELOCELE (OPEN SPINE) OR ANENCEPHALY? BLOOD OR BLEEDING DISORDERS (HEMOPHILIA, THALASSEMIA, SICKLE CELL ANEMIA)? MUSCLE OR NERVE DISORDERS (MUSCULAR DYSTROPHY, MYOTONIC DYSTROPHY, HUNTINGTON’S DISEASE)? CYSTIC FIBROSIS, TAY SACHS, CANAVAN DISEASE, GAUCHER DISEASE, NIEMANN-PICK, BLOOM SYNDROME, FANCONI ANEMIA A CHROMOSOMAL DISORDER OR BIRTH DEFECT OR ABNORMAL FACIAL STRUCTURE SUCH AS CLEFT PALATE? RETARDATION, AUTISM OR FRAGILE (X) SYNDROME? KIDNEY DISEASE, CLEFT LIP/PALATE, HEART DEFECTS? STILLBORN BABY OR BABY THAT DIED IN THE FIRST YEAR OF LIFE? DIFFICULTY BECOMING PREGNANT OR MAINTAINING A PREGNANCY OR 2 OR MORE MISCARRIAGES? Y N HAS THIS BABY’S MOTHER (IMMEDIATELY BEFORE OR DURING THIS PREGNANCY) BEEN: USING ANY MEDICINE (LITHIUM, ACCUTANE, ANTICONVULSANTS OR OTHERS)? USING ANY DRUGS (COCAINE, ALCOHOL, MARIJUANA, CIGARETTES, TOBACCO, UPPERS, DOWNERS, OR OTHERS)? EXPOSED TO X-RAYS OR CHEMICALS AT HOME OR AT WORK? INFECTED WITH OR EXPOSED TO INFECTIOUS DISEASE? HAD A FEVER OVER 101 DEGREES F OR A RASH? EXPOSED TO CAT LITTER? COUNSELING GIVEN ON TOXOPLASMOSIS _________. Y N IS THIS BABY’S MOTHER OR FATHER OR OTHER RELATIVE OF: ASHKENAZI JEWISH, CAJUN, OR FRENCH-CANADIAN BACKGROUND? IS TAY SACHS DISEASE IN THE FAMILY? TAY SACHS TEST ORDERED ________. IS SICKLE CELL ANEMIA IN THE FAMILY? SICKLE CELL PREP ORDERED ______. MEDITERRANEAN, ASIAN, MIDDLE EASTERN, ITALIAN OR BACKGROUND? ARE THE BABY’S MOTHER AND FATHER GENETICALLY RELATED (COUSINS OR OTHER BLOOD RELATIVES)? IS THIS BABY’S MOTHER OR FATHER INFECTED WITH HERPES OR ANY OTHER SEXUALLY TRANSMITTED I HAVE DISCUSSED THE ABOVE QUESTIONS WITH THE DOCTOR. ALL QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. IT IS STRONGLY RECOMMENDED THAT I SEEK ADDITIONAL GENETIC COUNSELING. AMNIOCENTESIS HAS BEEN OFFERED. FURTHER GENETIC COUNSELING CHOSEN _________________________________________________________ AMNIOCENTESIS CHOSEN _____________________________________________________________________ _______________________________________________________________________________________________ PATIENT SIGNATURE _______________________________________________________________________________________________ GENETIC SCREENING QUESTIONNAIRE6/11/2007 Miami Beach Community Health Center 710 Alton Road, Miami Beach, FL 33139 1221 71st Street, Miami Beach, FL 33141

Source: http://www.miamibeachhealth.org/files/GeneticScreeningQuestionaireEnglish.pdf