Patient Name:    ___________________________        Date of Birth:    ____________________

Hexosaminidase A, serum (for non-pregnant patients not taking oral contraceptives)

Hexosaminidase A, leukocytes (for pregnant patients or those taking oral contraceptives)

Cystic fibrosis carrier testing

Ashkenazi Jewish carrier screening by molecular analysis for the following disorders:

Tay-Sachs disease

Canavan disease

Familial dysautonomia

Fanconi anemia type C

Niemann-Pick disease type A

Bloom syndrome

Mucolipidosis IV

Glycogen storage disease type 1

Gaucher disease (non-neuronopathic type)
 

Family history of any of these disorders:
 

NO                YES:    _______________________________

Pregnancy in progress:
 

NO                    YES:  LMP ________________   /   EDC by U/S  ___________________

Ethnicity:
 

European-Jewish (Ashkenazi) | Caucasian (non-Jewish) | Hispanic | Asian | African-American

Other ethnicity:    ________________________________________________
 

Additional history:    ___________________________________________________________________
 

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