May 2016 PATIENT HISTORY FORM FOR NON-INVASIVE PRENATAL TESTING (NIPT) Patient Name Date of Birth Ordering Provider Physician Phone Physician FAX Physician Pager/Cell: Genetic Counselor Genetic Counselor Phone Draw Date: Gestational Age at Draw: weeks days Fetal gender by ultrasound: [ ] Male [ ] Female [ ] Ambiguous [ ] Unknown Patient’s current weight __________ lbs (or) _______ kgs Patient’s height ___________inches (or) _______ cm Is the patient carrying more than one fetus, or is there a known twin demise? Yes* No Unknown Is the patient the genetic mother of the fetus (i.e. was the fetus conceived using the patient’s own egg) ? Yes No* *This screen is NOT appropriate when there is more than one fetus/twin demise or when the patient is not the genetic mother of the fetus. If you have questions, please contact genetics at 800-242-2787 x2141 before drawing the patient. Indication for testing (check all that apply): Advanced Maternal Age: [ ] Primigravida / 1st Trimester (009.511) [ ] Multigravida / 1st Trimester (009.521) [ ] Primigravida / 2nd Trimester (009.512) [ ] Multigravida / 2nd Trimester (009.522) [ ] Ultrasound Abnormality (O28.3):(please describe) [ ] Family History (Z82.8):(please describe) [ ] Personal History (Z13.79):(please describe) Abnormal Antenatal Screening (Mother): [ ] hematological (O28.0) [ ] biochemical (O28.1) [ ] cytological (O28.2) [ ] radiological (O28.4) [ ] chromosomal (O28.5) [ ] Other (O28.8) Supervision of: high risk pregnancy: [ ] 1st trimester (009.891) [ ] 2nd trimester (009.892) pregnancy infertility: [ ] 1st trimester (009.01) [ ] 2nd trimester (009.02) pregnancy with poor reproductive or obstetric history: [ ] 1st trimester (009.291) [ ] 2nd trimester (009.292) pregnancy due to assisted reproductive technology: [ ] 1st trimester (009.811) [ ] 2nd trimester (009.812) Maternal care for: [ ] (suspected) chromosomal abnormality in fetus, fetus 1 (35.1XX1) [ ] (suspected) hereditary disease in fetus, fetus 1 (35.2XX1) [ ] (suspected) fetal abnormality and damage, fetus 1 (O35.8XX1) [ ] Other: (please describe) Please Circle the test you intend to order 2007537 Non-Invasive Prenatal Testing for Fetal Aneuploidy Screening test for fetal aneuploidy involving chromosomes 13, 18, 21, X and Y 2010232 Non-Invasive Prenatal Testing for Fetal Aneuploidy with Microdeletions Screening test for fetal aneuploidy involving chromosomes 13, 18, 21, X and Y, as well as for deletions causing DiGeorge/Velocardiofacial, 1p36, Angelman, Cri-du- chat and Prader-Willi syndromes 2013142 Non-Invasive Prenatal Testing for Fetal Aneuploidy with 22q11.2 Microdeletion Screening test for fetal aneuploidy involving chromosomes 13, 18, 21, X and Y, as well as for deletions causing DiGeorge/Velocardiofacial syndrome. PLEASE SUBMIT ARUP TEST REQUISION IN ADDITION TO THIS PATIENT HISTORY FORM 500 Chipeta Way, Salt Lake City, Utah 84108-1221 Phone: (800) 522-2787 Fax: (801) 584-5249 Web site: www.aruplab.com I want to know the sex of the fetus (sex will be reported if nothing is checked) [ ] Yes [ ] No Billing Information: [ ] ARUP client bill [ ] Patient bill (patient insurance information required)