Geneticist    _________________________________________        Date    ____________________

Institution    _______________________________________________________________________

Phone    ________________     Fax    ________________   Email    __________________________

Cytogenetic diagnosis (chromosomes involved & breakpoints); please do not send copies of the reports.

        __________________________________________________________

How the translocation was ascertained  (please circle):

    Child with unbalanced translocation      Multiple miscarriages/ infertility      Fortuitously

Age of female carrier, or age of partner of male carrier   ___________________

A full THREE GENERATION pedigree - limited to the translocation carrier's side of the family:

Additional information :