Birth Defects Risk Assessment

    African American/Black
    Yes   No

    Greek, Italian, Middle Eastern or Asian
    Yes   No

    Eastern European (Ashkenazi) Jewish or French Canadian
    Yes   No

    Down Syndrome (Mongolism / Trisomy 21) or other chromosome problem
    Yes   No

    Neural tube defect (opening in the spine, spina bifida, anencephaly)
    Yes   No

    Mental Retardation / developmental delay
    Yes   No

    Fragile X syndrome
    Yes   No

    Huntington disease
    Yes   No

    Cystic fibrosis
    Yes   No

    Muscular dystrophy or other muscle or nerve problems
    Yes   No

    Hemophilia or any other bleeding disorder
    Yes   No

    Other genetic condition
    Yes   No

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.)
    Yes   No

8. Have you, your partner or any other family member been born with a heart defect?
    Yes   No

9. Do you or your partner have a history of three or more miscarriages or a stillbirth?
    Yes   No

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?
    Yes   No

    Seizure/epilepsy medications (Dilantin®, Tegretol®, etc.)
    Yes   No

    Lithium for depression
    Yes   No

    Accutane or other pills for acne
    Yes   No

    Any other medications of concern
    Yes   No

12. Have you used any of the following while pregnant?