Revised 09/2019

Genetic/Family History Questionnaire

Patient Name: _____________________________________Date of Birth: __________________Date: _____________

How would you describe your ancestry? Please check all that apply.

□ Other: _______________________________________ □ Other: __________________________________

Are you and the father of this baby a blood relative (i.e. cousins)? Yes ______ No ______

What is your occupation? ____________________________________________________

What is the name of the father of this baby? _____________________________________

What is the occupation of the father of this baby? _________________________________

What is the age of the father of this baby? ____________________________________________

How would you describe the ancestry of the father of this baby? Please check all that apply.

□ Other: _______________________________________ □ Other: __________________________________

Is the father of this baby your partner? Yes ______ No ______

Is this pregnancy a Product of IVF? Yes ______ No ______ If yes:

Was a donor egg used? Yes ______ No ______

What is the age of the donor? ____________________

Comments: _______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

1

□ White □ French Canadian □ Samoan □ Vietnamese

□ African (Black) □ Native American □ Chinese □ Laos

□ Hispanic □ Greek □ Cambodian □ Taiwanese

□ Ashkenazi Jewish □ Italian □ Filipino □ Korean

□ Cajun □ Middle Eastern □ Japanese □ Other Southeastern Asian

□ Guamanian □ Hawaiian □ Asian- East Indian □ Unknown Race

□ White □ French Canadian □ Samoan □ Vietnamese

□ African (Black) □ Native American □ Chinese □ Laos

□ Hispanic □ Greek □ Cambodian □ Taiwanese

□ Ashkenazi Jewish □ Italian □ Filipino □ Korean

□ Cajun □ Middle Eastern □ Japanese □ Other Southeastern Asian

□ Guamanian □ Hawaiian □ Asian- East Indian □ Unknown Race

Revised 09/2019

Genetic/Family history Questionnaire

Do you or the father of this baby, or any close relatives have:

Thalassemia (Greek, Mediterranean, or Asian Background) MCV < 80 □ Yes □ No

Neural Tube Defect (Meningomyelocele Spina Bifida or Anencephaly) □ Yes □ No

Congenital Heart Defect □ Yes □ No

Down syndrome □ Yes □ No

Tay-Sachs (Jewish, Cajun, French Canadian) □ Yes □ No

Sickle Cell Disease or Trait (African) □ Yes □ No

Hemophilia or Bleeding Problems □ Yes □ No

Muscular Dystrophy □ Yes □ No

Cystic Fibrosis □ Yes □ No

Canavan Disease □ Yes □ No

Mental Retardation / Autism / Learning Disorder □ Yes □ No

If Yes, Tested for Fragile X □ Yes □ No

Huntington Chorea □ Yes □ No

Other inherited Genetic or Chromosomal Disorder □ Yes □ No

Maternal Metabolic Disorder (insulin Dependent Babies, PKU) □ Yes □ No

Patient or Baby’s father had a child with birth defects NOT listed above? □ Yes □ No

If yes, describe __________________________________________________________________

Recurrent pregnancy Loss or Stillbirth □ Yes □ No

Blindness or Deafness □ Yes □ No

Bone or Skeletal Disorder (Dwarfism) □ Yes □ No

Breast, Ovarian, Or Colon Cancer □ Yes □ No

Kidney Disorder □ Yes □ No

Do either of you or any of your parents, siblings or children have Diabetes? □ Yes □ No

Blood/Clots / Stroke □ Yes □ No

Have you taken any medications other than Prenatal Vitamins since pregnancy? □ Yes □ No

Have you used any street drugs since becoming pregnant?

If yes, please list substance: _________________________________ How often? ____________

□ Yes □ No

Have you consumed any alcoholic beverages since becoming pregnant?

If yes, please list substance: _________________________________ How often? _____________

□ Yes □ No

Do you currently smoke? □ Yes □ No

Anything else that runs in the family? __________________________________________________ □ Yes □ No

Comments: ________________________________________________________________________________

__________________________________________________________________________________________

Reviewed By: _____________________________________________________

2

Revised 09/2019

Review of Systems Questionnaire

Have you been screened to see if you are a carrier for inherited diseases such as cystic fibrosis, thalassemia, sickle cell

trait, spinal muscular atrophy (SMA), or Fragile X? Yes ______ No ______

If so, are you a carrier of any known inherited disease? Yes ______ No ______

If yes, which one(s)? ___________________________________________________________________

Have you or your partner travelled to Florida this pregnancy, or anywhere outside the United States?

Yes ______ No ______

If yes, where and when? _______________________________________________________________

Do you have a history of preeclampsia in any previous pregnancy? Yes ______ No ______

Preferred Pharmacy: _____________________________________ Phone Number: _________________________

Do you or have you taken medication in the last year?

Medications Taken Dose Frequency Date Started

Do you have any known drug allergies?

Drug Reaction Severity ( mild, moderate, or severe)

Revised 09/2019

Review of Systems Questionnaire

Do you have a past or current history of any Psychiatric Disorders, Depression, or Postpartum Depressions?

Yes ______ No ______ If yes, please state the condition(s) and when diagnosed.

Date Condition

Do you have any medical problems (Example: Diabetes, High Blood Pressure, Thyroid)?

Medical Issue Date

Past Surgeries: (Example: Appendectomy, Cervical Colonization, LEEP, Laparoscopy, Hysteroscopy)

Surgery Date

Previous Pregnancies:

Year Outcome

(full term, preterm, miscarriage, termination)

Gestational Age (# of Weeks at

delivery)

Type of delivery (vaginal cesarean, forceps, vacuum)

Weight and Gender

Complications

4

Revised 09/2019

Revised 09/2019

Revised 09/2019

Houston Center for Maternal Fetal Medicine

Patient Registration Form

PATIENT INFORMATION

How well do you speak English? ____Very Well ____Well ____Not Well ____Not At All

Name (First, Middle, Last) ___________________________________________________Date of Birth: __________

Mailing Address: _________________________________________City, State, Zip: ______________________________

Tel#: ___________________________________Alt#:_______________________Email: __________________________

Social Security Number: ___________________ Marital Status: Single ____ Married_____ Divorced____ Widowed____

Patient Employer: ______________________________________ Work Phone: ________________________________

SPOUSE/GUARDIAN INFORMATION

Name: _______________________________________________________ Date of Birth: _________________

Social Security Number: ___________________Relationship to Patient: ________________ Tel#: ___________________

Employer: ________________________________ Work Phone number: __________________________

EMERGENCY INFORMATION

Name: __________________________________________________ Tel#:: _____________________________________

PATIENT RESPONSIBILTY

I authorize the release of any medical records or other information necessary to process my insurance claims on my

behalf. I authorize Obstetrix Medical Group of Houston to appeal all insurance claims as appropriate on my behalf. I

agree to be fully responsible for all lawful debits incurred by myself for services whether or not covered by insurance.

Signature: ____________________________________________ Date: _______________________________

Revised 09/2019

Revised 09/2019

Revised 09/2019

Revised 09/2019

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION TO FAMILY AND FRIENDS

I authorize the practice to discuss appointment dates, time, location, medical history, diagnosis, treatment, prognosis,

financial, insurance and billing information with those listed below. I understand that my or my child’s healthcare

provider will use his/her judgment in sharing this information in order to foster continuity of care. The release of copies

of medical records will require a signed HIPAA- compliant authorization. This permission will be considered on-going

until I indicate otherwise in writing.

PHI may be released to the following individuals:

1._______________________________________________________________

2._______________________________________________________________

3._______________________________________________________________

4._______________________________________________________________

Yes______ No______ The practice staff have my permission to share my or my child’s personal health information

with family members or others who are in the room with me/us during the appointment.

The practice staffs have my permission to leave messages concerning treatment (i.e. Lab Results) on my:

(Please check all that apply)

_____ Home Voicemail/Answering machine Home Phone number: _______________________________

_____ Cellphone Cell Phone number: _________________________________

_____ Work voicemail Work Phone number: ________________________________

_____ NO INFORMATION: I do not authorize the release of any verbal information (other than appointment reminders

to the number(s) that I have provided).

_____________________________________________ ____________________________________________

Print Name of Patient *Print Name of Authorized Representative

____________________________________________ _____________________________________________

Patient/Authorized Representative Signature Date Signed

Authorized Representative’s authority to act on the Patient’s behalf:

Parent/legal guardian Power of Attorney

*Evidence of Authority must be provided and on file with the practice.

COMPLY.PRI.018.001 Rev.Date 04/08/2019