Patient Information
& Pregnancy Questionnaire

Section 1.
Patient Information

Name:
Date of Birth (M/D/Y):
Occupation:
Address:
City:
State:   Zip:
County (CA only):
Referring Physician:
Home #:
Cell #:
Work #:

Section 2.
Partner Information (if the patient is pregnant, then "partner" is the father of the pregnancy)

Name:
Date of Birth (M/D/Y):
Occupation:

Section 3.
Pregnancy Information

Are you currently pregnant?
if yes, what is your due date:
Please list any medications you take on a regular basis:
If pregnant, please list any other medications you have taken during this pregnancy (other than prenatal vitamins or Tylenol):

Section 4.
Since becoming pregnant, have you had any
(or if not pregnant please check current exposure)

Recreational Drugs:
Cigarettes:
Alcohol:
Fevers:
X-rays:

Section 5.
Do you have any of the following conditions?

Diabetes?
A seizure disorder?

Section 6.
Confidential or Private Messages

Genzyme Genetics/Esoterix Genetic Laboratories, LLC has my permission to leave detailed messages about confidential medical information and test results at the number(s) noted below.
Patient Home:
Cell:
Work:
Who else can we leave test results with?
Phone:
If there is a phone number at which we may leave confidential messages, please sign the release below:
I, , give Genzyme Genetics/Esoterix Genetic Laboratories, LLC permission to leave messages about confidential medical information and test results at the number noted below.
Confidential phone number:

I HAVE ANSWERED THE ABOVE QUESTIONS TO THE BEST OF MY KNOWLEDGE