Has any member of your family (father, mother, brother, sister) suffered from one of the following conditions before the age of 65?
You are not required to disclose a family history of hypertension, high cholesterol, or depression.
- Multiple sclerosis
- Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
- Polycystic kidney disease**
- Death from an unknown cause
- Cardiovascular disease (e.g.: CVD, myocardial infarction)
- Parkinson’s disease
- Neurological disease** (excluding epilepsy)
- Alzheimer’s disease
- Huntington’s chorea**
- Any other hereditary disorder** (specify):
- I don’t know since I was adopted, or I have no contact with my family
- None of the Above