Family History Questionnaire
Please correct the errors described below.
Does, or did anyone in your families (you, your children, parents, grandparents, siblings, aunt, or uncle), or any children from other marriages have, or died from:
AIDS/ HIV or other immune deficiency disease
High cholesterol, triglycerides, lipids
Intestinal problems, ulcer, colitis
Allergies , asthma, hay fever
Kidney disease (stone etc.)
Anemia, blood problems
Liver disease (hepatitis, etc
Arthritis, (lupus, juvenile arthritis, gout, etc.)
Lung disease, cystic fibrosis, tuberculosis
Babies with SIDS, congenital heart disease
Migraine or severe headaches
Muscle or nerve disease
Cancer or leukemia
Celiac disease Celiac disease
Scoliosis, bone problems
Diabetes (less than age 30)
Seizures, convulsions, retardation
Genetic problems (Tay Sachs, Down’s, etc.)
Skin disease (psoriasis, eczema, etc.)
Hearing / Vision problems (other than glasses)
Testicular, ovarian or uterine problems
Heart attack or stroke (less than age 60)
High Blood Pressure ( Hypertension)
Please write here if the illness is not on the list
Does anyone smoke in the house?
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