OBSTETRIC MEDICAL HISTORY

The following questions pertain to the genetic makeup of (or "genetics") of the current pregnancy. Please answer "yes" if the following applies to any person who is genetically related to the baby.

What ethnicity/race do you self-identify with? List one or more, as applicable

What is the paternal (baby's father) ethnicity/race? List one or more, as applicable

Please check if the baby has one of the following genetic backgrounds:

Ashkenazi

YesNoI don't know

Black/African American

YesNoI don't know

Mediterranean or South Asian Ancestry

YesNoI don't know

French Canadian or Cajun Ancestry

YesNoI don't know

Has there been any testing for the following conditions in any of the baby's genetic relatives? This may have been performed in a previous pregnancy or related to a family history of these conditions.

	Self	Other Genetic Relative
Tay-Sachs
Canavan
Familial dysautonomia
Sickle Cell
Inherited forms of anemia
Cystic Fibrosis
Spinal Muscular Atrophy
Genetic Carrier Screening

If Genetic Carrier Screening was performed, when was it performed and what was the result?

Date

Result

Date

Result

Date

Result

Date

Result

2. Does the baby have any genetic relatives born with a birth defect?

YesNo

If yes, please describe

3. Please describe any special needs that have occurred in genetic relatives of the baby (eg, developmental delay/cognitive impairment/intellectual disability, early infant death, special education, genetic conditions such as hemophilia, sickle cell disease, cystic fibrosis). If there are any persons, please list their problem.

How is this child/person related to you?

4. Is there a history of pregnancy loss (miscarriages or stillbirths)?

YesNo

If yes, has there been genetic counseling?

YesNo

If yes, has there been genetic testing related to the history of pregnancy loss?

YesNo

If yes, do you know what the results were and where/when you had this testing performed?

5. Do you have a family history of fragile X syndrome, intellectual disabilities/cognitive delays, autism, or premature ovarian failure?

YesNo

If yes, what were the results and when and where were this testing performed?

Screening

Date

Result

6. Please list any other concerns you have about birth defects or inherited disorders

7. Do you want screening test(s) to look for genetic or chromosomal problems like Down syndrome during your pregnancy?

YesNoI don't know

OBSTETRIC MEDICAL HISTORY

Pregnancy History

Exposures Affecting Health

Gynecologic Health History

Family History and Genetic Screening

Psychosocial Screening