Center for Fetal Medicine and Women’s Ultrasound

6310 San Vicente Blvd. | Suite 520 | Los Angeles, CA 90047 Tel: 323-857-1982 | Fax: 323-857-5336

Family History Questionnaire

Patient Information

Partner Information: (If pregnant, then “partner” is the genetic / biological father of the pregnancy)


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 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 you families ever had the following conditions:

Yes No Yes No
Down syndrome
Heart defect at birth
Other chromosomal problem
Cleft lip / cleft palate
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,
Yes No
Is there a history of infertility in you or your partner?
If YES: Yes No Did you use? Yes No
Was this pregnancy achieved with IVF?
Intracytoplasmic sperm injection (ICSI)?
Was an egg / sperm donor used?
Pre-implantation genetic diagnosis (PGD)
Mental retardation
Blindness / deafness
Autism
Baby who died after birth or within 1st year
Spina bifida (open spine)
Stillborn or 2 or more pregnancy losses
Anencephaly (opening in head / brain)
Any birth defect not listed above
Blood disorder, ex. Hemophilia or sickle cell
Any other inherited genetic condition
Muscular dystrophy or neuromuscular disease
Any other serious medical condition or surgery
Cystic fibrosis
Any known syndrome
Yes No
Have you had:
First trimester screening?
Integrated second trimester screening
Date of blood draw
Screening results:
Free-cell DNA prenatal testing
Prenatal diagnosis via chorionic villus sampling (CVS)
Prenatal diagnosis via amniocentesis
Please complete the following information:

Yes No
Medications (other than prenatal vitamins and iron:

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

I have answered these questions to the best of my knowledge

 

Center for Fetal Medicine

Our Location

6310 San Vicente Blvd,
Suite 520
Los Angeles, CA 90048

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm

2001 Santa Monica Blvd,
Suite 870W
Santa Monica, CA 90404

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm

6310 San Vicente Blvd, Suite 520 Los Angeles, CA 90048 | 323.857.1952

Important insurance information!

Please be sure to visit our Patient Information page prior to your visit!

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