Family Origin Questionnaire origin... · 2007. 10. 5. · Africa (excluding North Africa) Any other...

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What are your family origins? Please tick all boxes in ALL sections that apply to the woman and the baby’s father A. AFRICAN OR AFRICAN-CARIBBEAN (BLACK) Woman Baby’s father Caribbean Islands Africa (excluding North Africa) Any other African or African-Caribbean family origins (please write in…) B. SOUTH ASIAN (ASIAN) Woman Baby’s father India or African-Indian Pakistan Bangladesh C. SOUTH EAST ASIAN (ASIAN) Woman Baby’s father China Thailand Malaysia, Vietnam, Philippines etc Any other Asian family origins (please write in…) (e.g. Caribbean-Asian) D. OTHER NON-EUROPEAN (OTHER) Woman Baby’s father North Africa, South America etc Middle East (Saudi Arabia, Iran etc) Any other Non-European family origins (please write in…) E. SOUTHERN & OTHER EUROPEAN (WHITE) Woman Baby’s father Cyprus Greece, Turkey Italy, Portugal, Spain Any other Mediterranean country Albania, Czech Republic, Poland, Romania, Russia etc F. * UNITED KINGDOM (WHITE) refer to chart Woman Baby’s father England, Scotland, N Ireland, Wales G. * NORTHERN EUROPEAN (WHITE) refer to chart Woman Baby’s father Austria, Belgium, Ireland, France, Germany, Netherlands Scandinavia, Switzerland etc Any other European family origins, refer to chart (please write in) (e.g. Australia, N America, S Africa) *Hb Variant Screening Requested by (F) and/ or (G) Woman Baby’s father H. DON’T KNOW (incl. pregnancies with donor egg/sperm) I. DECLINED TO ANSWER J. ESTIMATED DELIVERY DATE (please write in if not above) The TOP (white) copy of this form must be attached securely to the laboratory antenatal booking request form and sent to the laboratory with the antenatal blood samples, the second (pink) copy is to be retained in the patient’s maternity notes, third (yellow) copy to go into hospital notes or where appropriate. If using a pre-printed label please attach one to each copy Hospital Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hospital No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NHS No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Estimated Delivery Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forename . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Add1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Add2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Post Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Screening test declined Do you want to give a reason why declined? Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Family Origin Questionnaire July 2007 DESTINATION (eg Community Midwife, GP, Antenatal Clinic, Obstetrician) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All women need to be informed that routine analysis of blood may identify them as a thalassaemia carrier. In low prevalence areas OFFER haemoglobin variant screening to all women if they or the baby's father have answers in any yellow box. In high prevalence areas OFFER haemoglobin variant screening to all women irrespective of answers, ie. if they or the baby's father have answers in white and yellow boxes A - I. Signed Print Name Job Title Date (By Health Care Professional Completing the Form) Any other relevant information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10680v11 Ethnic Questionnaire_AW:10418 Ethnic Questionnaire 297x216 27/7/07 15:37 Page 1

Transcript of Family Origin Questionnaire origin... · 2007. 10. 5. · Africa (excluding North Africa) Any other...

  • What are your family origins?Please tick all boxes in ALL sections that apply to the woman and the baby’s fatherA. AFRICAN OR AFRICAN-CARIBBEAN (BLACK) Woman Baby’s father

    Caribbean IslandsAfrica (excluding North Africa)Any other African or African-Caribbeanfamily origins (please write in…)

    B. SOUTH ASIAN (ASIAN) Woman Baby’s fatherIndia or African-IndianPakistanBangladesh

    C. SOUTH EAST ASIAN (ASIAN) Woman Baby’s fatherChinaThailandMalaysia, Vietnam, Philippines etcAny other Asian family origins (please write in…) (e.g. Caribbean-Asian)

    D. OTHER NON-EUROPEAN (OTHER) Woman Baby’s fatherNorth Africa, South America etcMiddle East (Saudi Arabia, Iran etc) Any other Non-European family origins (please write in…)

    E. SOUTHERN & OTHER EUROPEAN (WHITE) Woman Baby’s fatherCyprusGreece, TurkeyItaly, Portugal, Spain Any other Mediterranean countryAlbania, Czech Republic, Poland, Romania, Russia etc

    F.* UNITED KINGDOM (WHITE) refer to chart Woman Baby’s fatherEngland, Scotland, N Ireland, Wales

    G.* NORTHERN EUROPEAN (WHITE) refer to chart Woman Baby’s fatherAustria, Belgium, Ireland, France, Germany, NetherlandsScandinavia, Switzerland etcAny other European family origins, refer to chart(please write in) (e.g. Australia, N America, S Africa)

    *Hb Variant Screening Requested by (F) and/ or (G)

    Woman Baby’s fatherH. DON’T KNOW (incl. pregnancies with donor egg/sperm)I. DECLINED TO ANSWERJ. ESTIMATED DELIVERY DATE

    (please write in if not above)

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    If using a pre-printed label please attach one to each copy

    Hospital Name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Hospital No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    NHS No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Estimated Delivery Date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Forename . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Add1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Add2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Post Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Screening test declinedDo you want to give a reasonwhy declined?

    Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    No

    Family Origin Questionnaire

    July 2007

    DESTINATION (eg Community Midwife, GP, Antenatal Clinic, Obstetrician) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    All women need to be informed that routine analysis of blood may identify them as a thalassaemia carrier. In low prevalence areas OFFER haemoglobinvariant screening to all women if they or the baby's father have answers in any yellow box. In high prevalence areas OFFER haemoglobin variantscreening to all women irrespective of answers, ie. if they or the baby's father have answers in white and yellow boxes A - I.

    Signed Print Name Job Title Date (By Health Care Professional Completing the Form)

    Any other relevant information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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  • Screening and Diagnostic Uses ofthe Family Origin Questionnaire

    In low prevalence areas the FamilyOrigin Questionnaire (FOQ) isprincipally used as a tool to identifywomen who are at highest risk ofbeing a carrier or having a baby with ahaemoglobin variant or disorder.Therefore you need to ask for thefamily origins of both the woman ANDthe baby's father going back at least 2generations (or more if possible).

    In high and low prevalence areasthe FOQ is used as a tool bylaboratory staff to help with theinterpretation of results, particularly inthe interpretation of results indicatingpossible alpha or beta thalassaemia.The family origin is also relevant inthe interpretation of red blood cellindices and essential for accurateprenatal diagnosis. More informationabout its use can found in thelaboratory handbook:http://www.sickleandthal.org.uk/Documents/LabHandbook2006.pdf.

    It will also identify women with sicklecell disorders, who should beconsidered high risk requiringspecialist care during pregnancy froman Obstetrician and Haematologist,and who should be booked for ahospital delivery.

    Family Origin Questionnaire Chart

    People with family origins from thecountries listed are at low risk forhaemoglobin variants.

    If a woman or the baby’s father hasfamily origins that are not listedbelow offer screening forhaemoglobin variants.

    United Kingdom (White)

    England, Scotland, Northern Ireland,Wales.

    Northern European (White)

    Austria, Belgium, Denmark,Greenland, Iceland, Ireland (Eire),Finland, France, Germany,Luxembourg, Netherlands, Norway,Sweden, Switzerland.

    Some populations of the followingcountries have Northern Europeanorigin (countries listed above) and arealso at low risk:

    Northern European Origin (White)

    Australia, North America (USA,Canada), South Africa, New Zealand.

    Guidance for Health Care Professionals

    If you need more Family Origin Questionnaires, pleasecontact your Health Promotion Unit. If this is not possible,call 0870 15 55 4 55 and quote ANSPFOQ07/07.

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