Have you or any members of your family been born with or affected by any known genetic problem, birth defects, or major medical problems?
1. Patient’s Age ≥ 35 yrs.
2. Father of baby ≥ 50 yrs.
3. Italian, Greek Mediterranean or Asian background (thalassemia)
4. Jewish, Cajun, Fr. Canadian background (Tay Sachs)
5. African or Latin American background (sickle cell)
6. Down syndrome or other chromosomal problem
7. Hemophilia or other bleeding disorder?
9. Adopted-family history unknown
10. Cystic Fibrosis or any other metabolic
12. Mental retardation or autism
13. Maternal medical problems (diabetes,
lupus, epilepsy, PKU, etc.)
14. Other inherited genetic or
15. Child with birth defects not listed above
16. ≥ 3 first trimester spontaneous
abortions or a stillbirth?