Center for Maternal and Fetal Medicine
PATIENT GENETIC SCREENING FORM
Counseling Date:
Indication:
Counseling session:
Physician:
Recommendations: ________________ ___________________________
Procedures performed:_
_______________________________________
NAME: Last:
First:
Maiden:
PHONE#: Home:
Work:
Mobile:
HOME ADDRESS:
DATE OF BIRTH:
BLOOD TYPE:
AGE:
RELIGION (optional):
LAST MENSTRUAL PERIOD (first day):
DUE DATE:
REFERRING PHYSICIAN:
TOTAL # OF PREGNANCIES:
voluntary terminations:
preterm deliveries:
miscarriages:
living children:
FATHER OF THIS PREGNANCY’S NAME:
Last:
First:
PHONE#: Home:
DATE OF BIRTH:
Work:
Mobile:
AGE:
RELIGION (optional):
Are you and the father of this pregnancy related by blood? YES___
NO ___
Attach patient label here
1. CURRENT PREGNANCY
 Complications (spotting, cramping, bleeding)?______________________________
 Exposure to medications (prescription, over the counter), recreational drugs, herbal remedies?
If yes please give name(s), amount and when it was taken:

Do you currently smoke? NO

Please indicate the amount of alcohol you have had during this pregnancy (include gestational
age at that time)
Have you had any exposure to chemicals/pesticides/X-rays/cat litter box during this pregnancy?
NO
YES (please list type, duration and gestational age at time of exposure)

YES (please list amount and how often) :

Have you had any exposure to infections during this pregnancy (fever,rash,etc.)
NO
YES(please list type, duration and gestational age at time of exposure)

Do you wish to know the sex of the baby? YES____
NO_____
2. MATERNAL MEDICAL HISTORY
Please list any medical conditions, major surgeries and/or hospitalizations you have experienced
throughout your life:
3. MATERNAL PAST PREGNANCY HISTORY
Please list all pregnancies (living, deceased, miscarriages, terminations). If any of these children
have/had any medical conditions or learning difficulties, please specify in the column to the right.
Date of birth
Sex
Full term
vaginal delivery?
Father’s name
Specify
4. FATHER OF THIS PREGNANCY’S HISTORY
 Please list any medical conditions, major surgeries and/or hospitalizations you have
experienced throughout your life:

Please list the sex and ages of your children from any previous relationships (please specify any
medical illnesses or learning difficulties):
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Attach patient label here
5. ETHNIC BACKGROUND
Mother:
Father:
Do you have any of the following in your background?
a. Jewish/French Canadian
Mother:
Father:
yes ___ no ___
yes ___ no ___
If yes, have you had carrier testing for Tay-Sachs disease, Canavan Disease, cystic fibrosis,
Familial dysautonomia, Fanconi anemia (group C), Niemann-Pick (Type A), Bloom Syndrome,
mucolipidosis IV and Gaucher disease (Type I)
yes ___ no ___
yes ___ no ___
yes ___ no ___
yes ___ no ___
If yes, please indicate results:
b. Black/East Indian
If yes, have you had carrier testing for Sickle cell disease or another Hemoglobin variant?
yes ___ no ___
yes ___ no ___
If yes, please indicate results:
c. Asian/Greek/Italian
yes ___ no ___
yes ___ no ___
If yes, have you had carrier testing for thalassemia?
yes ___ no ___
yes ___ no ___
If yes, please indicate results:______________________________________
Have you had carrier screening for cystic fibrosis? Yes__ No__
If yes, please indicate results: _____________________________
Have you had carrier screening for spinal muscular atrophy (SMA)? Yes__ No__
If yes, please indicate results:___________________________________
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Attach patient label here
6. FAMILY HISTORY
Please check below if any of the following occurred in your families (siblings, parents,
nieces/nephews, aunts/uncles, cousins, grandparents – living or deceased)
Birth defects
Infant or childhood deaths
Mental retardation
Muscular Dystrophy
Blindness
Deafness
Dwarfism
Hemophilia or bleeding disorder
Thrombophilia (blood clotting disorder)
Down syndrome
Other chromosome problem
Specify:
Fragile X syndrome
Polycystic kidney disease
Emphysema (early onset, nonsmoker)
Any other genetic conditions not listed
Specify:
Congenital heart defect
Spina bifida or anencephaly
Cleft lip and/or palate
Hydrocephalus (water on the brain)
Cystic fibrosis
Sickle cell disease or trait
Thalassemia disease or carrier
Tay-Sachs disease or carrier
Phenylketonuria
Other metabolic disease
Other metabolic disease
Specify:
Huntington’s disease
Early onset cancer
Early onset heart disease
If you checked any of the above conditions, please indicate the person’s relationship to you or the
baby’s father, the condition and the cause (if known):
Patient Signature__________________________Date__________Time______
Provider Signature________________________ Date__________Time_______
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Attach patient label here
This page will be completed during the genetic counseling appointment.
Date:
Informant:
Time:_______
Hosp. No.:
Page:
Diagnosis:
By:
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