Family Origin Questionnaire origin... · 2007. 10. 5. · Africa (excluding North Africa) Any other...
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)
The
TOP
(wh
ite)
co
py
of
this
fo
rm m
ust
be
atta
ched
sec
ure
ly t
o t
he
lab
ora
tory
an
ten
atal
bo
oki
ng
req
ues
t fo
rm a
nd
sen
t to
th
e la
bo
rato
ry w
ith
th
e an
ten
atal
blo
od
sam
ple
s, t
he
seco
nd
(p
ink)
co
py
is t
o b
e re
tain
ed in
th
e p
atie
nt’s
mat
ern
ity
no
tes,
th
ird
(ye
llow
) co
py
to g
o in
to h
osp
ital
no
tes
or
wh
ere
app
rop
riat
e.
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10680v11 Ethnic Questionnaire_AW:10418 Ethnic Questionnaire 297x216 27/7/07 15:37 Page 1
-
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.
10680v11 Ethnic Questionnaire_AW:10418 Ethnic Questionnaire 297x216 27/7/07 15:37 Page 2