MUSC Women's Care

musc women's care

Genetic Screening Form

Please fill out the following form before arriving for your pre-natal genetic counseling appointment.  Thank you.
Have you, the father of the baby, or anyone in either of your families had any of the following:
Down Syndrome, mental retardation or slowness?*
Spina Bifida (open spine) or anencephaly (open head)?*
Hemophilia (free bleeding)?*
Muscular Dystrophy?*
Hydrocephalus (water on the brain)?*
Cystic Fibrosis (genetic lung disease)?*
Neurological disorders (including seizures)?*
Deafness or blindness?*
Sickle Cell Anemia or Thalassemia?*
Any other birth defect (even one surgically corrected)?*
Any other inherited problem?*
Are you or is the father of the baby:
African American, Caribbean Hispanic or East Indian?*
If yes, have either of you been screened for sickle cell trait?
Jewish (Ashkenazic/Eastern European), French-Canadian or Cajun?*
If yes, have either of you had Tay-Sachs carrier screening?
Italian or Greek?*
If yes, have either of you had Thalassemia carrier testing?
Have you taken any medication or street drug since becoming pregnant? (Do not include vitamins, iron, or acetaminophen [Tylenol])*
Fields marked with * are required.
 
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MUSC Health
171 Ashley Avenue
Charleston, SC 29425
843-792-1414
 
 

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