Birth Defects Risk Assessment

 
* = required fields
This questionnaire is for screening only. It does not guarantee the birth of a healthy baby.
Material Characteristics
SOME MATERIAL CHARACTERISTICS CAN AFFECT YOUR PREGNANCY:
1. Will you be age 35 or older when you deliver?
 
2. Have you had, or do you now have, epilepsy or seizures?
 
3. Are you a diabetic?
 
4. Could you and your partner be related (first cousins, etc.)?
 
Ethnic Groups
SOME HEALTH PROBLEMS ARE MORE COMMON IN CERTAIN ETHNIC GROUPS:
5. Are you or your partner?
    African American/Black
 
    Greek, Italian, Middle Eastern or Asian
 
    Eastern European (Ashkenazi) Jewish or French Canadian
 
Family History
FAMILY HISTORY CAN ALSO BE IMPORTANT:
6. Have you, your partner, or anyone in either of your families had any of the following?
    Down Syndrome (Mongolism / Trisomy 21) or other chromosome problem
 
    Neural tube defect (opening in the spine, spina bifida, anencephaly)
 
    Mental Retardation / developmental delay
 
    Fragile X syndrome
 
    Huntington disease
 
    Cystic fibrosis
 
    Muscular dystrophy or other muscle or nerve problems
 
    Hemophilia or any other bleeding disorder
 
    Other genetic condition
 
7. Have you, your partner, or anyone in your families had a birth defect? (such as: cleft lip, blindness, deafness, hydrocephaly (water on the brain), etc.)
 
8. Have you, your partner or any other family member been born with a heart defect?
 
9. Do you or your partner have a history of three or more miscarriages or a stillbirth?
 
10. Many common diseases such as cancer or Alzheimer’s disease may have a genetic cause. This is more likely if there are several family members with the same health problems. Is there any major health problem that is common in your family?
 
Medications
SOME MEDICATIONS CAN AFFECT YOUR PREGNANCY:
11. Have you taken any of these medications while pregnant?
    Seizure/epilepsy medications (Dilantin®, Tegretol®, etc.)
 
    Lithium for depression
 
    Accutane or other pills for acne
 
    Any other medications of concern
 
12. Have you used any of the following while pregnant?
    Alcohol
 
    Recreational drugs (We do a urine drug screen at all NOB visits)
 
    Any other drugs that concern you
 
13. Have you been around any chemicals that concern you?
 
Please discuss any “YES” answers with your physician/health care provider. In some cases, further evaluation by a genetic counselor may be suggested.

I have read all of the above questions carefully, and understand that this information is important for my health care providers to determine if my baby could be at an increased risk to have an inherited disease or birth defect. I also understand that 2-3% of babies are born with a birth defect. Many birth defects cannot be detected before birth and may occur with no family history

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