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.
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Cancer*
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Multiple sclerosis
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Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
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Polycystic kidney disease**
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Death from an unknown cause
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Cardiovascular disease (e.g.: CVD, myocardial infarction)
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Parkinson’s disease
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Neurological disease** (excluding epilepsy)
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Hemophilia**
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Diabetes
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Alzheimer’s disease
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Huntington’s chorea**
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Any other hereditary disorder** (specify):
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I don’t know since I was adopted, or I have no contact with my family
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None of the Above