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Family History Questionnaire

Download a PDF of the Genetic Family History & Pregnancy Questionnaire.

Genetic Family History & Pregnancy Questionnaire

Date of Appointment _____________

Section 1. Patient Information


Patient’s name _______________________________________________________

Date of Birth _________________________________________________________

Occupation __________________________________________________________

Address _____________________________________________________________

City_________________________________________ State _____ Zip _________

Home Phone ____________ Work Phone ____________ Cell Phone _____________

Referring Physician’s Name ______________________________________________

Referring Physician’s Phone Number _______________________________________

Section 2. Partner Information (if patient is pregnant, “partner” means the father of the pregnancy)

Partner’s name _______________________________________________________

Date of Birth _________________________________________________________

Occupation __________________________________________________________

The following questions may help your doctor or genetic counselor complete a genetic risk assessment and determine if certain genetic tests are appropriate. If you are unsure about your family history, please speak with family members.

Section 3. Are you or your partner from any of these ethnic backgrounds?

Ethnic Background

Patient

Partner

Chinese, Taiwanese, Asian Indian, Pakistani, Filipino or Southeast Asian

    

Italian, Greek, Middle Eastern, Spanish or Portuguese

    

Jewish, French Canadian or Cajun

    

African American, African descent, Black, Puerto Rican, Caribbean or Central American

    

Hispanic or Mexican

    

Caucasian

    

Other (specify)

    

Section 4. Have you, your partner or anyone in your families ever had the following conditions:

Condition

Yes

No

Down syndrome

    

Other chromosome problem

   

Mental retardation, autism, or developmental delay

    

Spina bifida (open spine)

    

Anencephaly (opening in head/brain)

    

Blood disorder, such as hemophilia or sickle cell

    

Muscular dystrophy or neuromuscular disease

    

Cystic fibrosis

    

Neurofibromatosis

    

Skeletal disorder, like dwarfism

    

Polycystic kidney disease

    

Huntington disease or other adult neurological diseases (e.g., dementia, Alzheimer’s)

    

Heart defect

   

Cleft lip/cleft palate

    

Blindness/deafness

    

Baby who died at birth or within first year

    

Stillborn or 2 or more pregnancy losses

    

Any birth defect not in this list

    

Any other inherited (genetic) condition

    

Any other serious medical condition or surgery

    

Are you or your partner adopted?

    

Are you and your partner related to each other (other than by marriage)?

    

Is there a history of infertility in either you and/or your partner?

    

Please specify the cause of infertility, if known.

    

Have you and/or your partner had:

    

    carrier testing for cystic fibrosis?

    

    carrier testing for any other genetic disorder?

    

    blood chromosome testing?

    

Section 5. Please complete the following patient information:

 

Yes

No

Current medications

If yes, please list:

    

Recreational drugs

    

Alcoholic drinks

    

Cigarette smoking

    

Do you have diabetes, PKU (phenylketonuria) or lupus?

    

Are you considering or have you used:

    

    egg donor or donor sperm?

    

    preimplantation genetic diagnosis (PGD) or preimplantation genetic screening (PGS)?

    

    intracytoplasmic sperm injection (ICSI)?

    

Section 6. If you are currently pregnant:

What is your due date?:

Have you had any of the following:

Yes

No

    Rashes, infections, fevers?

    

    Spotting, bleeding or any other complications?

    

    Exposure to X-rays?

    

    Maternal serum screening (AFP blood screen, AFP3, Afp4®, triple marker screen, first trimester screen)?

    

I have answered these questions to the best of my knowledge.

__________________________________________________
Patient’s signature

___________
Date