MUSC Women's Care

musc women's care

Genetic Screening Form

Please fill out the following form before arriving for your prenatal genetic counseling appointment.  Your information is secure.  Click here to read our privacy statement.  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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