genetic/family history questionnaire - mednax...2019/09/10 · if yes, tested for fragile x yes no...
TRANSCRIPT
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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: _______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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□ 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
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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: _____________________________________________________
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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)
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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
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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: _______________________________
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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