Hospitalizations / Hospitalizaciones

Name/Nombre

Date of Birth/Fecha de Nacimiento

Fill in the information for each time you have been in the hospital. Include any surgeries you have had on an outpatient basis / LIene cada vez que a estado en el hospital

Hospitalization 1

Date you were hospitalized / Fecha

Reason Hospitalized / Razon

Who was your doctor / Doctor que lo receto

What hospital were you in / Hospital que lo receto

Medication Name / Nombre de Medicamento

Prescribing Doctor's Name / Doctor que lo receto

Reason for taking the medication / Razon

Dosage / Dosis

How often / Cada Cuando

Hospitalization 2

Date you were there / Fecha

Reason Hospitalized / Razon

Who was your doctor / Doctor Nombre

What hospital were you in / Hospital Nombre

Medication Name / Nombre de Medicamento

Prescribing Doctor's Name / Doctor que lo receto

Reason for taking the medication / Razon

Dosage / Dosis

How often / Cada Cuando

Hospitalization 3

Date you were there / Fecha

Reason Hospitalized / Razon

Who was your doctor / Doctor que lo receto

What hospital were you in / Hospital

Medication Name / Nombre de Medicamento

Prescribing Doctor's Name / Doctor que lo receto

Reason for taking the medication / Razon

Dosage / Dosis

How often? Cada Cuando?

Hospitalization 4

Date you were there / Fecha

Reason Hospitalized / Razon

Who was your doctor / Doctor que lo receto

What hospital were you in / Hospital

Medication Name / Nombre de Medicamento

Prescribing Doctor's Name / Doctor que lo receto

Reason for taking the medication / Razon

Dosage / Dosis

How often / Cada Cuando

Hospitalization 5

Dates you were there / Fecha

Reason Hospitalized / Razon

Who was your doctor / Doctor

What hospital were you in / Hospital

Medication Name / Nombre de Medicamento

Prescribing Doctor's Name / Doctor que lo receto

Reason for taking the medication / Razon

Dosage / Dosis

How often / Cada Cuando

GENETIC SCREENING & TERATOLOGY COUNSELING / DETECCION GENETICO Y CONSEJERIA

Includes patient, baby's father, or anyone in either family / incluya paciente, padre del bebe y familiares

1. PATIENT'S AGE 35 YEARS OR OLDER AS OF ESTIMATED DATE OF DELIVERY / PACIENTE TENDRA MAS DE 35 ANOS AL DAR ALUZ

Yes / Si No

2. THALASSEMIA (ITALIAN, GREEK, MEDITERRANEAN OR ASIAN BACKGROUND) MCV<80 / ORIGINARIOS DE IT ALIA, ASIA, MERITERRANIO

Yes / Si No

3. NEURAL TUBE DEFECT (MENINGOMYELOCELE, SPINA BIFIDA OR ANENCEPHALY / DEFECTO NEURO (ESPINEBIFERA-EJEMPLO)

Yes / Si No

4. CONGENITAL HEART DEFECT / DEFECTO CONGENITAL DEL CORAZON

Yes / Si No

5. DOWN SYNDROME/ SYNDROMA DE DOWNS

Yes / Si No

6. TAY-SACHS (EG. JEWISH, CAJUN, FRENCH CANADIAN) / TAY-SACHS (JUDIOS, CANADIENSES)

Yes / Si No

7. CANAVAN DISEASE / ENFERMEDAD CANAVAN

Yes / Si No

8. SICKLE CELL DISEASE OR TRAIN (AFRICAN) / ENFERMEDAD DE CELULA SICKLE

Yes / Si No

9. HEMOPHILIA OR OTHER BLOOD DISORDERS / DESORDEN DE SANGRE o HEMOFILIA

Yes / Si No

10. MUSCULAR DYSTROPHY / DISTROFIA MUSCULAR

Yes / Si No

11. CYSTIC FIBROSIS / FIBROSIS CISTICO

Yes / Si No

12. HUNTINGTON'S CHOREA / CHOREA DE HUNTINGTON

Yes / Si No

13. MENTAL RETARDATION or AUTISM / RETARDACION MENTAL o AUTISTA

a. If yes, was person tested for Fragile X / esa persona a sido examinada para Fragile X

Yes / Si No

14. OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER / DESORDEN HEREDITARIA CHROMOSONAL o GENETICO

Yes / Si No

15. MATERNAL MEABOLIC DISORDER (TYPE 1 DIABETES, PKU) / DESOROEN METABOLICO MATERNAL (DIABETES)

Yes / Si No

16. PATIENT OR BABY'S FATHER HAD A CHILD WITH BIRTH DEFECTS NOT LISTED ABOVE / PACJENTE/PADRE DE BEBE TUVO UN BEBE CON DEFECTOS

Yes / Si No

17. RECURRENT PREGNANCY LOSS OR STILLBIRTH / PERDIDAS DE EMBARAZO RECORRIENTES

Yes / Si No

18. MEDICATIONS (INCLUDING SUPPLEMENTS, VITAMINS, HERBS OR OTC DRUGS) ILLICIT/RECREATIONAL DRUGS/ALCOHOL SINCE LAST MENSTRUAL PERIOD / MEDICAMENTOS (VITAMINAS, HJERBAS, DROGAS, ALCOHOL DESDE SU ULTIMA MENSTRUACION)

Yes / Si No

19. ANY OTHER / OTRA COSA

Yes / Si No

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