GREENVILLE MIDWIFERY CARE
Name: ______________________________
PRENATAL GENETIC SCREENING QUESTIONNAIRE
MR#: __________________________________
These questions apply to members in both your family and in the baby’s father’s family:
1. How old will you be when your baby is born?
_______________
2. How old will the father of the baby be when your baby is born?
_______________
3. Have you or the baby’s father or anyone in either of your families ever had a baby or family member with:
a. Down Syndrome or other chromosome abnormality?
 Yes  No
b. Spina Bifida or neural tube defect (open spine or brain)?
 Yes  No
c. Hydrocephalus (water on the brain)?
 Yes  No
d. Anencephaly (open or missing brain)?
 Yes  No
e. Hemophilia or other blood disorders (bleeds easily)?
 Yes  No
f. Muscular Dystrophy?
 Yes  No
g. Cystic Fibrosis?
 Yes  No
h. Congenital heart defect?
 Yes  No
i. Mental Retardation?
 Yes  No
4. Have you or the baby’s father or other close relative had:
a. An infant born dead (stillborn)?
 Yes  No
b. Three or more pregnancy losses?
 Yes  No
c. A baby with a birth defect?
 Yes  No
5. Are you or the baby’s father of Mediterranean descent, or have a history of Thalassemia?
 Yes  No
6. Do you or the baby’s father have sickle cell trait or anemia?
 Yes  No
7. Do you or the baby’s father have Jewish relatives, or have a family history of Tay-Sachs?
 Yes  No
8. Do you know of any genetic (inherited) health problem in your family or the father’s family?
 Yes  No
9. Is there any other health problem that you are concerned about in you or your baby’s father?
 Yes  No
Explain:
___________________________________________________________________________________________
HIV Screening: HIV transmission from mother to baby can occur during pregnancy and birth. In the event a mother tests
positive for the HIV virus during pregnancy, there are special medications and treatments available that can greatly
reduce the risk of transmission from mother to baby. Because of this, the Centers for Disease Control (CDC) and the
American Academy of Pediatrics (AAP) recommend routine HIV screening for all pregnant women and routine testing of
all newborns born to mothers with unknown HIV status at the time of delivery. It is the policy of Greenville Midwifery
Care to perform HIV testing in all pregnant women at the initial prenatal visit unless the mother specifically requests not
to have testing performed. The test for HIV is a blood test that is ordered along with the routine prenatal labs.
I understand the risks to myself and my baby of unidentified HIV infection.
□ I agree to HIV testing
□ I do not want HIV testing.
JFPCNM July 2014
CF Carrier Testing: I have received a booklet about Cystic Fibrosis Carrier Testing. I understand this is a screening test for
Cystic Fibrosis that cannot detect all Cystic Fibrosis Carriers.
 Yes
I want Cystic Fibrosis Carrier Screening
 No
Nuchal Translucency Ultrasound Screening (NT screening) : I have received a brochure explaining First Trimester
Maternal Serum Screening and Nuchal Translucency Ultrasound (NT Screening). I understand that NT screening is a test
for Down syndrome, which occurs at a rate of 1 in 700 babies, trisomy 13, which occurs at a rate of 1 in 10,000 and
trisomy 18 which occurs at a rate of 1 in 8000. First trimester screening will detect about 95% of pregnancies with
trisomy 13 or 18. This test is done between 11-13 weeks of pregnancy if I desire.
 Yes
I want NT Screening
 No
QUAD Screening: I have received a brochure explaining Multiple Marker Screen for neural tube defects (spina bifida),
Down’s Syndrome, and Trisomy 18. I understand that the Multiple Marker Screen is a test for open-spine defects, which
occur at a rate of 1-4 per 1000 pregnancies. This test can be drawn at 16-20 weeks gestation if I desire.
 Yes
I want Multiple Marker screening
 No
I understand that genetic counseling and prenatal diagnosis can be arranged if I desire.
__________________________________________________________________________
Patient Signature
Date
___________________________________________________________________________
Provider or nurse signature
Date
Genetic Screening Referral:
 No
 Yes
 Declined
Appointment Date / Time: _______________________________________________________
_______________________________________________________________________________________________
Reviewed By
JFPCNM July 2014
Date