NIFTY questionnaire – Physician

IMPORTANT: If the details given in the questionnaire change on the day of sampling, definitely contact us to update your details. The form may not work properly in Internet Explorer. We recommend that you complete it in Google Chrome.

1. Full name:

1a. Do you wish your name to be included on the test result?:

2. Date of Birth:

3. Phone number:

4. E-Mail:

5. Identity card number or, in the absence of an identity card, passport number:

6. Weight and height:

7. Age of the fetus in weeks and days according to the ultrasound:

Week:

Day:

8. Do you wish sex information on the result?:

9. Singleton/multiple pregnancy:

10. Do you take any medication?:

11. Therapy with heparin or heparin analogues within the year before sampling:

12. Do you have an abnormal karyotype result?:

13. Does the father of the baby have an abnormal karyotype result?:

14. Transplantation:

15. Abnormal reproductive history:

16. Cancer history:

17. I declare that I do not suffer from infectious diseases:

18. Do you wish to have incidental findings reported?:

19. Past stem cell therapy:

20. Received allogeneic blood transfusion within one year:

21. A cellular immunotherapy treatment in which exogenous DNA was introduced within 4 weeks:

22. Received albumin:

23. Received immunotherapy:

24. In vitro fertilisation:

25. Vanishing twin syndrome:

26. One fetus has malformations (applies to twin pregnancies):

27. Physician’s full name:

28. Name of the facility:

29. The physician's e-mail address:

30. Date and time of material collection:

Remarks:

Patient's details

1. Full name*: (First name) (Last name)

1a. Do you wish your name to be included on the test result? *:Yes and I agree that my personal information in the form of my name will be forwarded to the BGI laboratory in Hong Kong for the test.No and I wish to have an identification number instead of my name on the test result. This also means that the NIFTY insurance will be waived.

2. Date of Birth*:

3. Phone number*:

4. E-mail*:

5. Identity card number or, in the absence of an identity card, passport number (this number is essential for insurance. Failure to provide it will result in the insurance being waived):?

I waive insurance

6. Weight and height*:(weight) kg,(height) cm,

7. Age of the fetus in weeks and days according to the ultrasound (as of the day the sample for the test was taken)*:?

8. Do you wish sex information on the result?*:YesNocolor:red;font-weight:bold

9. Singleton/multiple pregnancy*:SingletonTwin3 and more fetuses

NIFTY test coverage for twin pregnancies includes: trisomy 21, trisomy 18, trisomy 13 and sex on request. Make sure the correct answer is ticked.

10. Do you take any medication?*:YesNo

11. Therapy with heparin or heparin analogues within the year before sampling*: (Neoparin, Clexane, Fraxiparine, Fragmin, Heparinum, Fraxiparin, Endoksyparin, Innohep, Oksapar, Tinzaparin, Lovenox, Enoxaparin).YesNo

12. Do you have an abnormal karyotype result?*:?NoYes, abnormal result (dup, del, t, rob, inv, p-/+, q-/+, +mar and chromosome aneuploidy)Yes, abnormal result ( qh+/-, ps+/-, pstk+/-, pss_)

13. Does the father of the baby have an abnormal karyotype result?*:NoYes

14. Transplantation*:YesNo

15. Abnormal reproductive history (repeated 2 or more times)*:?YesNo

16. Cancer history*:NoYes, recoveryYes, disease continues (cancer)Yes, disease continues (malignant neoplasm)

17. I declare that I do not suffer from infectious diseases (infectious samples are not accepted for testing)*:I am not illI am ill

18. Do you wish to have incidental findings reported? (Incidental findings are included in the price of the test). It may happen that the test detects abnormalities outside the scope of NIFTY and consent is needed to share the result. These arrangements are not covered by NIFTY*:NoYescolor:red;font-weight:bold

19. Past stem cell therapy*:?YesNo

20. Received allogeneic blood transfusion within one year*:YesNoIndicate when the last treatment took place:

21. A cellular immunotherapy treatment in which exogenous DNA was introduced within 4 weeks.*:YesNoIndicate when the last treatment took place:

22. Received albumin (human serum albumin) therapy*:?Yes and the interval between the last injection and the NIFTY sample collection is more than 4 weeks.Yes and the interval between the last injection and the NIFTY sample collection is less than 4 weeks.No

23. Received immunotherapy*:?Yes and the interval between the last injection and the NIFTY sample collection is more than 4 weeks.Yes and the interval between the last injection and the NIFTY sample collection is less than 4 weeks.NoIndicate when the last treatment took place:

24. In vitro fertilisation *:YesNo

25. Vanishing twin syndrome (suspected twin pregnancy)*:?Yes and more than 8 weeks passed between the end of the developmental arrest and the NIFTY sample collection and the developmental arrest ended within 8 weeks of pregnancyYes and less than 8 weeks passed between the end of the developmental arrest and the NIFTY sample collection and/or the developmental arrest ended later than 8 weeks of pregnancyNoTermination date: