Name
*
First Name
Last Name
Email
*
example@example.com
Have you, your partner or anyone in your family or your partner's family had:
*
Diabetes
Hypertension
Heart disease
Autoimmune disorders (rheumatoid arthritis, lupus, etc.)
Kidney disease
Epilepsy
Psychiatric disorders
Hepatitis
Depression
Thyroid disease
Preeclampsia
Difficult labor
None
Are there any genetic conditions in your family or your partner's, such as:
*
Down syndrome
Any chromosomal abnormality
Neural tube defects, including spina bifida, meningocele and anencephaly
Hemophilia
Muscular dystrophy
Connective tissue disease
Neurological disorders
Intellectual disabilities or autism
Tay-Sachs disease
Thalassemia
Sickle cell disease
Cystic fibrosis
Phenylketonuria (PKU)
Hearing loss
Canavan disease
Huntington's disease
Other genetic disorders
None
You selected "intellectual disabilities or autism". Was the person tested for fragile X syndrome?
*
Yes
No
Are there any sets of fraternal twins or other multiples in your family?
*
Yes
No
Are there any allergies in your family, including food allergies?
*
Yes
No
Has anyone in your family had recurrent miscarriages or stillbirths?
*
Yes
No
Has there been a history of violence, trauma or physical, sexual, oremotional abuse in your family, or in your relationship?
*
Yes
No
During your pregnancy have you used any of the following? Check the box and enter the type of
Substance
Indicate Type
How Often?
Alcohol
Amphetamines
Antibiotics
Antihistamines
Aspirin
Barbiturates
Caffeine
Cancer medicine
Cocaine
Convulsion medicine
Cortisone
Diet pills
Heart/blood pressure pills
Heroin
Hormones
LSD
Marijuana
Nausea medicine
Nerve pills/tranquilizers:
Nose drops
Sleeping pills
Thalidomide’s
Tobacco
Any other prescription drugs
Submit
Should be Empty: