logo color FormHeader BirthDefects
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This questionnaire is for screening only. It does not guarantee the birth of a healthy baby.
First Name *MILast Name *
SOME MATERIAL CHARACTERISTICS CAN AFFECT YOUR PREGNANCY:
1. Will you be age 35 or older when you deliver? YesNo
2. Have you had, or do you now have, epilepsy or seizures? YesNo
3. Are you a diabetic? YesNo
4. Could you and your partner be related (first cousins, etc.)? YesNo
SOME HEALTH PROBLEMS ARE MORE COMMON IN CERTAIN ETHNIC GROUPS:
5. Are you or your partner?  
  African American/Black YesNo
    If yes, have you or your partner been tested for sickle cell anemia? YesNoDon’t Know
    Have you or your partner been tested for thalassemia? YesNoDon’t Know
  Greek, Italian, Middle Eastern, or Asian YesNo
    If yes, have you or your partner been tested for thalassemia? YesNoDon’t Know
  Eastern European (Ashkenazi) Jewish or French Canadian YesNo
    If yes, have you or your partner been tested for Tay Sachs disease? YesNoDon’t Know
FAMILY HISTORY CAN ALSO BE IMPORTANT:
6. Have you, your partner, or anyone in either of your families had any of the following?  
  Down Syndrome (Mongolism/Trisomy 21) or other chromosome problem YesNo
  Neural tube defect (Opening in the spine, spina bifida, anencephaly) YesNo
  Mental Retardation/developmental delay YesNo
  Fragile X syndrome YesNo
  Huntington disease YesNo
  Cystic Fibrosis YesNo
  Muscular dystrophy or other muscle or nerve problems YesNo
  Hemophilia or any other bleeding disorder YesNo
  Other genetic condition YesNo

 

7.

Have you, your partner, or anyone in your families had a birth defect?
(such as: cleft lip, blindness, deafness, hydrocephaly (water on the brain), etc.)

YesNo
      If yes, please describe:
8.
Have you, your partner or any other family member been born with a heart defect? YesNo
9.
Do you or your partner have a history of three or more miscarriages or a stillbirth? YesNo
    If yes, was there a reason for these miscarriages? YesNo
10.
Many common diseases such as cancer or Alzheimer’s disease may have a genetic cause. This is more likely if there are several family members with the same health problems. Is there any major health problem that is common in your family? YesNo
      If yes, please describe:
SOME MEDICATIONS CAN AFFECT YOUR PREGNANCY:
11.
Have you taken any of these medications while pregnant?  
    Seizure/epilepsy medications (Dilantin®, Tegretol®, etc.) YesNo
    Lithium for depression YesNo
    Accutane or other pills for acne YesNo
    Any other medications of concern YesNo
      If yes, please describe:
12.
Have you used any of the following while pregnant?  
    Alcohol YesNo
    Recreational drugs (We do a urine drug screen at all NOB visits) YesNo
    Any other drugs that concern you YesNo
      If yes, please describe:
13.
Have you been around any chemicals that concern you? YesNo
      If yes, please describe:
Please discuss any “YES” answers with your physician/health care provider. In some cases, further evaluation by a genetic counselor may be suggested.
I have read all of the above questions carefully, and understand that this information is important for my health care providers to determine if my baby could be at an increased risk to have an inherited disease or birth defect. I also understand that 2-3% of babies are born with a birth defect. Many birth defects cannot be detected before birth and may occur with no family history
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date

Provider Signature (optional) ________________________________________________________ Date ________________