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Center for Maternal & Fetal Care Medical History Form

* Denotes required fields
Previous Ultrasounds (this pregnancy)

Past Medical History

Please check all that apply for Patient
Please check all that apply for Family
* Are you allergic to latex?

Genetic Screen

* Will you be age 35 or older when the baby is due?
Have you, or the baby's father, or anyone in either of your families ever had: (Please check all that apply)
Have you, or the baby’s father, had a child born dead or alive with a birth defect not listed above?
Do you, or the baby’s father, have any close relative with mental retardation?
Do you, or the baby’s father, or close relatives in either of your families, have any genetic disease or chromosomal disorder not listed above? (May include blindness or deafness, dwarfism, cystic kidneys, multiple brown or white skin patches, or large red birthmarks, etc.)
Have you had two or more miscarriages?
Do you, or the baby’s father, have any close relatives descended from: (Please check all that apply)
Are you and the baby’s father, related in any way (for example, second cousins)?
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