Family History 5-11

Please specify family members using the following initials of whom had the following illnesses.

M- Mother F- Father B- Brother S- Sister PG-Paternal Grandfather PGM -Paternal Grandmother MG - Maternal Grandfather MGM - Maternal Grandmother

Allergies: *

Family Member:

Anemia: *

Family Member:

Arthritis: *

Family Member:

Autoimmune Disease: *

Family Member:

Asthma/Emphysema *

Family Member:

Birth Defects: *

Family Member:

Blood Disease *

Family Member:

Bone/Muscle Disease *

Family Member:

Cancer *

Family Member:

If yes, specify type of Cancer:

Cystic Fibrosis: *

Family Member:

Drug/Alcohol Abuse: *

Family Member:

Diabetes: *

Family Member:

Eye/Ear Disorder: *

Family Member:

Heart Disease: *

Family Member:

Heart Attack < 50: *

Family Member:

High Blood Pressure: *

Family Member:

Infections: *

Family Member:

Kidney/Liver Disease: *

Family Member:

Learning Problems: *

Family Member:

Mental Illness/Retardation: *

Family Member:

Metabolic/Genetic Disorder: *

Family Member:

Nerve Disorder (Epilepsy): *

Family Member:

Rheumatic Fever: *

Family Member:

Sickle Cell Trait/Disease: *

Family Member:

Skin Disease: *

Family Member:

Tuberculosis or Exposure: *

Family Member:

Thyroid Disease: *

Family Member: