Microsoft word - genetic_eng.doc

Genetic Screening Questionnaire
Date:__________________ Patient’s Name:___________________________ Due Date:__________________ This questionnaire will provide us with information about your genetic background. Please answer all the questions as well as you can. Yes No_ Don’t Know
1) Will you be 35 years old by the time of your due date? . . . . . . . . . . . . . . . . . . . ___ 2) Is your partner 50 years of age or older? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ 3) Have you, your partner or anyone in either family (blood relatives) had any of a. Birth defects (describe below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ b. Mental retardation or mental deterioration . . . . . . . . . . . . . . . . . . . . . . . . . ___ c. Unexplained infant or childhood deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ d. Chromosome disorders (Down’s Syndrome, mongolism, trisomy 13 or 18, translocations – describe) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ e. Two or more miscarriages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ f. Enzyme or metabolic diseases, cystic fibrosis . . . . . . . . . . . . . . . . . . . . . . ___ g. Spina bifida, anencephaly, meningomyelocele (malformations of the brain or openings in the spine) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ h. Hydrocephalus (“water-on-the-brain”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ i. Congenital heart malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ j. Malformations of other organs (describe below) . . . . . . . . . . . . . . . . . . . . ___ k. Muscular dystrophy, myotonic dystrophy or progressive muscle wasting ___ l. Hemophilia (blood clotting problems) . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ m. Any other birth defects or inherited disorders . . . . . . . . . . . . . . . . . . . . . . ___ If yes to any of the above, please explain: ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4) Is there any of the following background in your family or your partner's a. Jewish (descendents from Eastern Europe-Ashkenazi Jews) . . . . . . . . . . . ___ b. Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ If yes, have you been tested for Sickle Cell trait? . . . . . . . . . . . . . . . . . . . . ___ c. Asian (Oriental) or Mediterranean (Greek, Italian) . . . . . . . . . . . . . . . . . . . ___ 5) What do you consider your race (ethnic background) to be? ____________________________________ Genetic Screening Questionnaire
Yes No_ Don't
6) Do you have any of the following disorders? a. Insulin dependent diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ b. Autoimmune disorders such as lupus or rheumatoid arthritis? . . . . . . . ___ c. Seizures or convulsions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ 7) Are you taking or do you use any of the following: a. Lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ b. Valium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ c. Accutane (a drug for acne) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ d. Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ e. Anticonvulsants (drugs for seizure such as Dilantin and Phenobarbital) ___ f. Iodides to treat hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ g. Anticancer drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ h. Birth control pills during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ i. Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ j. Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ k. Other drugs (describe below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___ If yes to any of the above, please explain: _________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Source: http://www.altosoaksmedicalgroup.com/docs/english/genetic_eng.pdf