Family History Questionnaire

Family History Questionnaire
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Occupation*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Tel*
Cell Tel*
.
Referring Physician*
Tel
Please enter a valid phone number.
Partner Information: (If pregnant, then “partner” is the genetic / biological father of the pregnancy)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Occupation
The following questions will help your medical care team complete a medical and genetic risk assessment for you. If you are unsure about your family history, please speak with family members to obtain that information.

Are you or your partner from any of these ethnic backgrounds? Please circle and check all that apply*

Rows	Yes	No
Chinese, Southeast Asian, Taiwanese, Filipino, Pacific Islander, Pakistani or Asian Indian
Spanish, Italian, Greek or Middle Eastern
Jewish, French Canadian or Cajun
African American, African descent, Black, Puerto Rican, Caribbean or Central American
Hispanic or Mexican
Caucasian
Other (specify)

Have you, your partner, or anyone in your families ever had the following conditions:*

Rows	Yes	No
Down Syndrome
Other chromosomal problem
Autism
Spina bifida (open spine)
Anencephaly (opening in head/brain)
Blood disorder, ex, Hemophilia or sickle cell
Muscular dystrophy or neuromuscular
Cystic fibrosis
Any known syndrome
Heart defect at birth
Cleft lip/ cleft palate
Blindness/ deafness
Baby who died after birth or within 1st year
Still born or 2 or more pregnancy losses
Any birth defect not listed above
Any other inherited genetic condition
Any other serious medical condition or surgery

Rows	Yes	No
Have you and/or your partner had carrier testing for cystic fibrosis?
Have you and/or your partner had carrier testing for Tay-Sachs?
Have you and/or your partner had testing for any other genetic disorders?
Are you or your partner adopted?
Are you and your partner related to each other – other than by marriage?
Have you ever had a pregnancy with growth restriction (IUGR)?
Have you ever had a baby born small for its age or delivered early because it was small?
Have you had genetic counseling with this pregnancy?
WITH A PREVIOUS PARTNER, have you or your partner ever had a miscarriage, stillbirth or infant death?

If YES:

Rows	Yes	No
Was this pregnancy achieved with IVF?
Was an egg / sperm donor used?

Did you use?

Rows	Yes	No
Intracytoplasmic sperm injection (ICSI)?
Pre-implantation genetic diagnosis (PGD)

Have you had:*

Rows	Yes	No
First trimester screening?
Integrated second trimester screening
Free-cell DNA prenatal testing
Prenatal diagnosis via chorionic villus sampling (CVS)
Prenatal diagnosis via amniocentesis

Please complete the following information:*

Rows	Yes	No
Medications (other than prenatal vitamins and iron:

Rows	Yes	No
Recreational drugs
Alcoholic drinks
Cigarette smoking
Diabetes or Lupus
Exposure to x-rays
Rashes, infectious diseases or fever
Spotting, bleeding or any other complication

Please select*

I am interested in a consultation with a genetic counselor to discuss ethnicity / carrier screening and/or family health concernsI am NOT interested in a consultation with a genetic counselor
Patient Signature
Date

MonthDayYear
Should be Empty: