MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01CAF0FA.43D715E0" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01CAF0FA.43D715E0 Content-Location: file:///C:/AAE86902/AAAGenassistFamilyProfileForm-web.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" GENETICS COUNSELING DICTATION FACTS Revised 2/21/96

&n= bsp;

GENASSISTTM FAMILY PROFILE FORM=

 =

INSTRUCTIONS:  Please complete this form with your partner by placing an “X” on each line that applies:=

 

&= middot;      =   If you are FEMALE:  Patient’s Name:________________________________  Date of Birth______

=  

=         &= nbsp;   How many children have you had?:

=  

=         &= nbsp;   Have you had previous genetic testing? &nbs= p;            &= nbsp;           YE= S        &= nbsp;        NO

=  

=         &= nbsp;   Have you had previous genetic counselling?        &= nbsp;           &nbs= p;          YES       &n= bsp;         NO

=  

=         =          If yes, please give results in detail:

=  

=  

=  

=  

=         &= nbsp;   Are you pregnant now?   YES  &n= bsp;           NO<= span style=3D'mso-tab-count:2'>        &= nbsp;         If you are pregnant now :

=  

=         &= nbsp;           &nbs= p;   What is the first day of your last menstrual period?:=

=  

=         &= nbsp;           &nbs= p;   When is your due date?:

=  

=         &= nbsp;   How many times have you been pregnant prior to now?:=

=  &nb= sp;            =           (includes miscarriages & abortions)

=  

=         &= nbsp;   How many children/live births have you had?:

=  

=         &= nbsp;   How many docume= nted spontaneous miscarriages have you had?:

=  

=         &= nbsp;   Have you ever had an “elective termination of a pregnancy – abortion)?     =          YES=             &nb= sp;     NO

=  

=         &= nbsp;           &nbs= p;   If yes, how many?:

=  

&= middot;      =   If you are MALE:=   Patient’s Name:____________________= _____________   Date of Birth_______

=  

=         &= nbsp;   How many children have you fathered?:

=  

=         &= nbsp;   Have you had previous genetic testing? &nbs= p;            &= nbsp;           YE= S        &= nbsp;        NO

=  

=         &= nbsp;   Have you had previous genetic counselling?        &= nbsp;           &nbs= p;          YES        &= nbsp;        NO=

=  

=         =          If yes, please give results in detail:=

=  

=  

 

1)      Are you and your spouse/partner related (i.e. do you have any blood relatives in common)?     YES        &= nbsp;           &= nbsp;   NO

 

   If yes, sp= ecify who:

 

 

 

2)      Are your or your spouse/partner adopted?  YES   &= nbsp;           &nbs= p; NO

 

  If yes, specify who:

 

 

 =

3)        What is your ethnic/racial background?  (Some inherited diseases are more common in certain ethnic groups).

 

   = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;             &= nbsp;   SELF               PARTNER

 

Black/African American        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;  _____        &= nbsp;     ______

 

Caucasian/White        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;         &= nbsp;   _____        &= nbsp;     ______

&= nbsp;          

Jewish            =             &nb= sp;            =             &nb= sp;                    &= nbsp;   _____        &= nbsp;     ______

 

Mediterranean (Greek, Italian)        &= nbsp;           &nbs= p;     _____        &= nbsp;     ______

 

Asian/Oriental            =             &nb= sp;            =             &nb= sp;         &= nbsp;   _____        &= nbsp;     ______

&= nbsp;          

Hispanic/Latino/Chicano/Central o= r S. American      = ;     _____        &= nbsp;     ______

 

Other, or combinations of above:

 

= (Specify):

=  

=  =

 

Does anyone in your family, or do you or your par= tner have any of the following?  *Include any previous partners with wh= om you have had children.**DO NOT include those who hav= e been adopted.

 = ;

1.  Infertility (Difficulty becoming pregnant for more than 6 months).

 

    &nbs= p;       YES        &= nbsp;          NO=             &nb= sp;   WHO:

=  

=    &nbs= p;        DESCRIBE

=  

=  

 

2.  More than one miscarriage and/or l= oss of baby.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

3.  History of diabetes and/or diabetes during pregnancy.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

DESCRIBE______________________________________________= _____________________<= /p>

______________________________________________________= _______________________

 =

4.  History of rapid or “painless” labor and/or premature birth.

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= _______________________

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

5.  History of stillbirth infant and/or child that died shortly after bi= rth (Include SIDS/Sudden Infant  

  &nbs= p; Death Syndrome).

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= __________________

=  

=         &= nbsp;   DESCRIBE__________________________________________= ____________________

=         =     ____________________________________________________________________= ____

 

6.  History of medical difficulties du= ring the  newborn period.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

7.  Development Delay (i.e motor, speech, etc.) or Learning Problems.

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= _______________________

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

8.  Mental Retardation.

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= _______________________

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

9.  Chronic Psychiatric, Psychological, Emotional or Behavioral Problems.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= __________

 

10.  Brain Abnormality/Fluid on the Bra= in (Hydrocephalus).

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

11.  Deafness/Ear Abnormalities.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

12.  Blindness/Eye Abnormalities.<= /o:p>

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

DESCRIBE______________________________________________= _____________________<= /p>

______________________________________________________= _______________________

 

13.  Lip/Mouth Deformity.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

14.  Cleft Palate/Cleft Lip.=

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

15.  Skin Abnormalities.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

16.  Spine Deformity/Spina Bifida.

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= _______________________

=  

DESCRIBE______________________________________________= _____________________<= /p>

 ___________________________________= _________________________________________

 

17.  Bone Deformity.<= /p>

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= _______________________

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

18.  Hand/Feet Abnormalities.

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= _______________________

=  

DESCRIBE______________________________________________= ____________________

______________________________________________________= ______________________

 =

 

19. Club Foot.

 

    &nbs= p;       YES____  NO____= _  WHO_______________________________= _______________________

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

20.  Heart Defect at Birth/Hole in Hear= t.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

21.  Heart Attack before Age 50.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

DESCRIBE______________________________________________= _____________________<= /p>

______________________________________________________= _______________________

 

22.  Seizures/Epilepsy/Convulsions/”Fits”.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= ________________________

=         =     ____________________________________________________________________= ________

 

23.  Muscle/Nerve Disorder.<= /span>

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

24.  Polycystic Kidneys/Horseshoe Kidne= y.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     _____________________________= ________________________________________________

 

25.  Bleeding Disorders.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

26.  Cystic Fibrosis.=

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =      ____________________________________________________________________= ________

 

   = ;         Have you been tested for Cystic Fibrosis?   

 

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________<= /o:p>

=  

=         &= nbsp;   Has your partner been tested for Cystic Fibrosis?

=  

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________

 

27.  Asthma/Severe Allergies.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= ________________________

=         =     ____________________________________________________________________= ________

 

28.  Phenylketonur= ia (PKU).

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= ________________________

=           =   ________________________________________________________= ____________________

 

29.  Hypothyroidism/Hyperthyroidism (Lo= w/High Thyroid Function).

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

30.  Thalassemia/Blood-Disorder.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

=         &= nbsp;  

Have you been tested for Thalasse= mia?   

 

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________<= /o:p>

=  

=         &= nbsp;   Has your partner been tested for Thalassemia?<= /o:p>

=  

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________

=  

31.  Hemophilia.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

DESCRIBE______________________________________________= _____________________<= /p>

 ___________________________________= _________________________________________

 

32.  Sickle Cell Disease or Trait.=

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

   = ;         Have you been tested for Sickle Cell Disease?   

 

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________<= /o:p>

=  

=         &= nbsp;   Has your partner been tested for Sickle Cell Disease?

=  

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________<= /o:p>

=  

33.  Tay Sachs Disease.

 

    &nbs= p;       YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=             _____= ________________________________________________________________________

 

   = ;         Have you been tested for Tay Sachs Disease?   

 

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________<= /o:p>

=  

=         &= nbsp;   Has your partner been tested for Tay Sachs Disease?=

=  

=         &= nbsp;           &nbs= p;   YES___  NO___<= span style=3D'mso-spacerun:yes'>  RESULTS_____________________

 

 

34.  Are you or your partner = taking any prescription medication for any medical disease (e.g. high blood <= /o:p>

pres= sure etc.  Specify the name of the drug (if k= nown).

 

=         &= nbsp;   YES____  NO____= _  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

35.  Diag= nosed genetic (inherited) disease.

 =

=         &= nbsp;   YES____  NO____= _  WHO_______________________________= _______________________

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=          ____________________________________________________________________= _____________

 

36.   Are there any other serious specific disorders, conditions, or unusu= al traits that run in your family or your

         partner’s family with or about whic= h you are concerned?

 

YES____  NO_____  WHO______________________________________________________=

=  

=         &= nbsp;   DESCRIBE__________________________________________= _________________________

=         =     ____________________________________________________________________= _________

 

Have you or your partner been= exposed to the following:

 

   = ;         Prescription Drugs

 

   = ;         YOU________PARTNER________

=  

= DESCRIBE______________________________________________________________________= _____

_________________________________________________= ____________________________________

 

= CHECK IF USED DURING THIS PREGNANCY_______

=  

Over= -the-Counter Drugs (i.e. aspirin, laxatives, sleeping pills, cold tablets, weight control medication, etc.)

 =

YOU________PARTNER________

 

DESCRIBE_____________________________________________<= /span>________________________= _

________________________= ________________________________________________________<= /p>

 

=  

=  

=  

=  

=  

=  

=  

=  

= CHECK IF USED DURING THIS PREGNANCY_______

=  

Recreational Drugs (i.e. Marijuana, Cocaine, LSD, etc)

 =

YOU________PARTNER________

 

DESCRIBE_____________________________________________<= /span>_______________________<= o:p>

________________________= ______________________________________________________

 

= CHECK IF USED DURING THIS PREGNANCY_______

=  

Environmental Agents (i.= e. Chemicals, cleaning agents, etc at home or work)

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= _______________________

______________________________________________________= _________________________

 

= CHECK IF USED DURING THIS PREGNANCY_______

=  

Alcohol:  Less than one<= span style=3D'mso-spacerun:yes'>  mixed drink, one glass of w= ine, or one beer per day.__________

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= _______________________

 

Alcohol:  One  mixed drink, two glasses of= wine, or two beers per day.__________

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= __________________

 =

Alcohol:  Three mixed drinks, three glasses = of wine, or three beers per day.__________

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= ______________________

 

Alcohol:  More than three mixed drinks, three glasses of wine or three beers per day.______

 

YOU________PARTNER________

 

DESCRIBE______________________________________________= _______________________

 

= CHECK IF USED DURING THIS PREGNANCY_______

=  

Cigarettes:  Less than one-half pack per day___= ___

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= ________________________

 

Cigarettes:  One-half  to one pack per day______

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= _________________________

 

Cigarettes:  One-to two packs per day______

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= _________________________

 

Cigarettes:  More than two packs per day______<= o:p>

 =

YOU________PARTNER________

 

DESCRIBE______________________________________________= _________________________

 

= CHECK IF EXPOSED DURING THIS PREGNANCY_______

=  

=         &= nbsp;   X-rays:

 

YOU________PARTNER________

 

DESCRIBE______________________________________________= _________________________

 

Are you or your partner being followed by a speci= alty physician for any chronic disease or condition?

 

   = ;         YOU____=

 

YES________NO________

 

DESCRIBE______________________________________________= _________________________

 

   = ;         PARTNER_______

 

YES________NO________

 

DESCRIBE______________________________________________= _______________________

 

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