GENASSIST

Your Genetic Profile

**Please print out the following genetic profile**
Please do not try to fill out this form online since GENASSIST does not want any medical information to be on the internet. ABSOLUTELY NONE of this information will travel over the internet, or will be available to anyone else besides yourself. Once you have printed out this form, please either bring it in to GENASSIST or your doctor.

Your Name:
Date of Birth:	Age:
Address:	City: State: Zip:
Telephone:	(Home) (Work)
Spouse's / Partner's Name:

Doctor's Name:
Doctor's Address:	City: State: Zip:
Telephone Number:

Medical Insurance:
Policy Number:

Your Sex: Male Female
How many children have you had or fathered?
Have you had previous genetic testing?
Have you had previous genetic counseling?
- If so, please explain:

For females:
Are you pregnant now? Yes No
- If so, what was the first day of your last period?
- When is your due date?
How many times have you been pregnant prior to now?
(Include miscarriages and abortions)
How many children/live births have you had?
How many documented spontaneous miscarriages have you had?
Have you ever had an "elective termination of a pregnancy" (abortion)? Yes No
- If so, how many?

Are you and your spouse/partner related?
(Do you have any blood relatives in common?)
Yes No Who:

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

Does anyone in your family, or do you or your partner have any of the following?

- Include any previous partners with whom you have had children.
- Do not include those who have benn adopted

1. Infertility (Difficulty becoming pregnant for more than 6 months.)
No	Yes	Who:
Describe:

2. More than One Miscarriage and/or Loss of Baby
No	Yes	Who:
Describe:

3. History of Diabetes and/or Diabetes during Pregnancy
No	Yes	Who:
Describe:

4. History of Rapid or "Painless" Labor and/or Premature Birth
No	Yes	Who:
Describe:

5. History of Stillborn Infant and/or Child that Died Shortly After Birth (Include SIDS/Sudden Infant Death Syndrome).
No	Yes	Who:
Describe:

6. History of Medical Difficulties during the Newborn Period
No	Yes	Who:
Describe:

7. Developmental Delay (i.e., Motor, Speech, etc.) or Learning Problems
No	Yes	Who:
Describe:

8. Mental Retardation
No	Yes	Who:
Describe:

9. Chronic Psychiatric, Psychological, Emotional or Behavioral Problems
No	Yes	Who:
Describe:

10. Brain Abnormality/Fluid on the Brain (Hydrocephalus)
No	Yes	Who:
Describe:

11. Deafness/Ear Abnormalities
No	Yes	Who:
Describe:

12. Blindness/Eye Abnormalities
No	Yes	Who:
Describe:

13. Lip/Mouth Deformity
No	Yes	Who:
Describe:

14. Cleft Palate/Cleft Lip
No	Yes	Who:
Describe:

15. Skin Abnormalities
No	Yes	Who:
Describe:

16. Spine Deformity/Spina Bifida
No	Yes	Who:
Describe:

17. Bone Deformity
No	Yes	Who:
Describe:

18. Hand/Feet Abnormalities
No	Yes	Who:
Describe:

19. Club Foot
No	Yes	Who:
Describe:

20. Heart Defect at Birth/Hole in Heart
No	Yes	Who:
Describe:

21. Heart Attack before Age 50
No	Yes	Who:
Describe:

22. Seizures/Epilepsy/Convulsions/"Fits"
No	Yes	Who:
Describe:

23. Muscle/Nerve Disorder
No	Yes	Who:
Describe:

24. Polycystic Kidneys/Horseshoe Kidney
No	Yes	Who:
Describe:

25. Bleeding Disorders
No	Yes	Who:
Describe:

26. Cystic Fibrosis
No	Yes	Who:
Describe:

27. Asthma/Severe Alleries
No	Yes	Who:
Describe:

28. PKU/Phenylketonuria
No	Yes	Who:
Describe:

29. Hypothyroidism/Hyperthyroidism (Low/High Thyroid Function)
No	Yes	Who:
Describe:

30. Thalassemia/Blood-Disorder
No	Yes	Who:
Describe:

31. Hemophilia
No	Yes	Who:
Describe:

32. Sickle Cell Disease or Trait
No	Yes	Who:
Describe:
Have you been tested for Sickle Cell Disease?
No	Yes	Results:
Has your partner been tested for Sickle Cell Disease?
No	Yes	Results:

33. Tay Sachs Disease
No	Yes	Who:
Describe:
Have you been tested for Tay Sachs Disease?
No	Yes	Results:
Has your partner been tested for Tay Sachs Disease?
No	Yes	Results:

34. Are you or your partner taking any prescription medication for any medical disease? (e.g., high blood pressure, etc? Specify name of drug, if known)
No	Yes	Who:
Describe:

35. Dignosed genetic (inherited) disease
No	Yes	Who:
Describe:

36. Are there any other serious specific disorders, conditions or unusual traits that run in your family or your spouse's/partner's family with or about which you are concerned?
No	Yes	Who:
Describe:

37. Have you or your spouse/partner been exposed to Prescription Drugs?
No	Yes	Who:
Describe:
Used during Pregnancy

38. Have you or your spouse/partner been exposed to Over-the-Counter Drugs? (Asprin, laxatives, sleeping pills, cold tablets, weight control medicine, etc.)
No	Yes	Who:
Describe:
Used during Pregnancy

38. Have you or your spouse/partner been exposed to Recreational Drugs? (Marijuana, Cocaine, LSD, etc.)
No	Yes	Who:
Describe:
Used during Pregnancy

39. Have you or your spouse/partner been exposed to Environmental Agents? (Chemicals, Cleaning Agents, etc. - at home or work)
No	Yes	Who:
Describe:
Used during Pregnancy

40. What is your alcohol usage?
Quantity: drink(s) or glass(es) of wine/beer per day
Describe:
Used during Pregnancy

41. What is your spouse's/partner's alcohol usage?
Quantity: drink(s) or glass(es) of wine/beer per day
Describe:
Used during Pregnancy

43. What is your tobacco usage?
Quantity: pack(s) of cigarettes per day
Describe:
Used during Pregnancy

43. What is your spouse's/partner's tobacco usage?
Quantity: pack(s) of cigarettes per day
Describe:
Used during Pregnancy

44. Have you or your spouse/partner ever been exposed to X-Rays?
No	Yes	Who:
Describe:

45. Are you or your spouse/partner being followed by a specialty physician for any chronic disease or condition?
No	Yes	Who:
Describe: