Family Medical History Form
Name
*
First Name
Last Name
Birthdate
*
/
Month
/
Day
Year
Date Picker Icon
Gender
Age
Height
Weight
Ethnic Origin
*
Eastern Europe & Russia
England, Wales & British Isles
Western & Germanic Europe
Baltic States
Nordic & Scandinavian
Mediterranean
Do you smoke?
Yes
No
Do you use tobacco products?
Yes
No
Do you use alcohol?
Yes
No
Please fill out the following questions according to the diseases in your family (multiple selection is possible).
Mother, father, brother, sister, uncle, aunt, grandmother, grandfather, cousin, etc.
Heart diseases&disorders
*
Bradycardia
Fibrillation
Tachycardia
Congenital heart disease
Congestive heart failure
Coronary artery disease
Dilated cardiomyopathy
High blood pressure
High cholesterol
Hypertrophic cardiomyopathy
Low blood pressure
Mitral regurgitation
Mitral valve prolapse
Pulmonary stenosis
Unknown
None
Other
Intellectual disabilities
*
Apert Syndrome
Cerebral Palsy
Down syndrome
Fetal alcohol syndrome
Fragile X syndrome
Prader-Willi Syndrome
Low IQ
Williams Syndrome
None
Other
Immunodeficiency diseases&disorders
*
Bruton’s disease
Common variable immunodeficiency
Digeorge syndrome
Immune-complex diseases
Job syndrome
Wiskott-Aldrich syndrome
X-linked agammaglobulinemia
None
Other
Kidney diseases&disorders
*
Abdominal Compartment Syndrome
Acetaminophen Nephrotoxicity
Kidney Failure
Kidney Injury
Chronic kidney disease
Nephronia / Nephropathy / Necrosis
Polycystic kidney disease
Unknown
None
Other
Lung diseases&disorders
*
Asthma
Chronic Bronchitis
COPD
Cystic Fibrosis
Emphysema
Pleural Effusion
Pneumonia
Pulmonary Hypertension
Tuberculosis
Tuberous Sclerosis
Unknown
None
Other
Mental illness
*
Anorexia nervosa
Bipolar Affective Disorder
Borderline Personality Disorder
Bulimia nervosa
Depression
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Panic disorder
Phobias
Schizophrenia and Other Psychoses
Social anxiety disorder
Unknown
None
Other
Sleep disorders
*
Hypersomnia / narcolepsy
Insomnia
Night terrors
Nocturia
Restless leg syndrome
Sleep apnea
Sleep paralysis
Sleepwalking
Sleeptalking
Unknown
None
Other
Muscular diseases&disorders
*
Amyotrophic lateral sclerosis (ALS)
Becker muscular dystrophy (BMD)
Dermatomyositis
Duchenne muscular dystrophy (DMD)
Inclusion body myositis
Myasthenia gravis
Polymyositis
Unknown
None
Other
Neurological diseases&disorders
*
Alzheimer's
Bell's palsy
Brain or spinal cord tumor
Carpal tunnel syndrome
Cervical spondylosis
Dementia
Encephalitis
Epidural abscess
Epilepsy
Guillain-Barré syndrome
Huntington chorea
Hydrocephalus
Meningitis
Multiple sclerosis
Neuralgia
Neuropathy
Parkinson’s disease
Unknown
None
Other
Ocular diseases&disorders
*
Astigmatism
Amblyopia (“lazy eye”)
Blue-yellow color blindness
Cataract
Diabetic retinopathy
Far-sighted (see distant objects)
Glaucoma
Injury or trauma
Macular degeneration
Near-sighted (see close objects)
Red-green color blindness
Strabismus (crossed eyes)
Unknown
None
Other
Skin diseases&disorders
*
Adult acne
Cellulitis
Cold sores
Dermatomyositis
Eczema
Hives
Psoriasis
Rosacea
Seborrheic dermatitis
Shingles
Unknown
None
Other
Strokes
*
Brain stem stroke
Cryptogenic stroke (unknown cause)
Hemorrhagic stroke (bleeds)
Ischemic stroke (clots)
Transient ischemic attack, “mini-stroke”
Unknown
None
Autoimmune diseases&disorders
*
Addison’s disease
Autoimmune vasculitis
Celiac disease
Graves’ disease
Hashimoto’s thyroiditis
Inflammatory bowel disease
Lupus
Multiple sclerosis
Myasthenia gravis
Pernicious anemia
Psoriasis/psoriatic arthritis
Rheumatoid arthritis (RA)
Sjögren’s syndrome
Unknown
None
Other
Blood diseases&disorders
*
Anemia
Hemophilia
Kostmann syndrome
Sickle cell disease
Von Willebrand disease
Unknown
None
Other
Bone and joint diseases&disorders
*
Bursitis
Fibrous Dysplasia
Gout
Osteoarthritis
Osteogenesis Imperfecta
Osteoporosis
Spinal Stenosis
Tendinitis
Unknown
None
Other
Cancers
*
Bladder Cancer
Breast Cancer
Colorectal Cancer
Endometrial Cancer
Kidney Cancer
Leukemia
Liver Cancer
Lung Cancer
Melanoma
Non-Hodgkin Lymphoma
Ovarian Cancer
Pancreatic Cancer
Prostate Cancer
Thyroid Cancer
Unknown
None
Other
Gastrointestinal diseases&disorders
*
Colon polyps
Crohn's disease
Diverticular disease
Irritable bowel syndrome
Ischemic colitis
Ulcerative colitis
Unknown
None
Other
Have you ever had an adverse or allergic reaction to any medication or treatment?
*
ACE inhibitors
Antiseizure drugs
Aspirin
Insulin
Latex rubber
Metals
Contrast dyes for X-rays and CT scans
Antibiotics such as Penicillin or Amoxicillin
Local anesthetics such as lidocaine and benzocaine
Monoclonal antibody therapy such as cetuximab (Erbitux) or rituximab (Rituxian)
Muscle relaxers given by IV such as atracurium, succinylcholine, or vecuronium
Narcotic analgesics like codeine, hydrocodone, oxycodone, morphine, or fentanyl
General anesthetics such as methohexital, propofol, thiopental, ketamine, or etomidate
Nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen
Sulfa-containing drugs or sulfonamide antibiotics,such as Bactrim or Septra
Unknown
None
Other
Additional Information
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