Circle the appropriate “no” or “yes” answers
1. If you are the baby’s father are one of the following racial backgrounds, have you been tested for:
a. Jewish of English European—Tay Sachs
b. Italian, Greek or Mediterranean—Beta Thalessemia
c. Southeast Asia or Philippine—Alpha/Beta Thalessemia
d. Black—Sickle Cell Trait
2. Will you be 35 years or older when the baby is born?
a.Will the baby’s father be 55 years or older when the baby is born?
3. Have you had 3 or more unplanned pregnancy losses?
4. Have you used any street drugs or chemicals(including marijuana and cocaine) in the last 6 months?
For the following questions, “close” relatives are considered grandparents, parents, aunts, uncles, brothers, sisters or
children of you or the baby’s father. Please circle if any close relative have had any of the following hereditary medical
5. A child with a known birth defect or stillborn?
6. Chromosome abnormalities?
i.e.Down Syndrome, Turner Syndrome, Klinefelters Syndrome, etc
7. Abnormalities of the brain or spinal column?
i.e. Hydrocephalus, spinal bifida, mental retardation, etc
8. Abnormalities of the bones or skeleton?
i.e. osteogenesis imperfect, achondroplasia, limb deformities, etc
9. Inherited disorders of the blood?
i.e. hemophilia, Sickle Cell disease or trait, Thalessemia, etc
10. Neuromuscular disorders?
i.e. Muscular Dystrophy, Myotonic dystrophy, etc
11. Metabolic or chemical disorders?
i.e. Tays Sach disease, cystic fibrosis, Hurler’s or Hunter’s syndrome, etc
12. Skin disorders?
i.e. Neurofibromatosis, ichthyosis, tuberous sclerosis, etc
13. Hereditary visual or hearing defects?
14. Unusual reactions to anesthetic agents?
i.e. hyperthermia, cholinesterase deficiency, etc
15. Other inherited disease not listed above?
i.e. Huntingtons chorea, polycystic kidney disease, congenital adrenal hyperplasia, etc
Known Genetic Risk FactorsYesNo
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