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Name
Date of Birth
Family History-Indicate which relative if other is chosen
Diagnosis
Alcohol/Drug Use
Alzheimer’s
dementia
Asthma
Autoimmune
disorder
Blood disorder
Breast Cancer
Colon Cancer
COPD (Emphysema)
Coronary Artery
Disease
CVA (Stroke)
Depression
Diabetes (childhood
onset)
Diabetes (adult
onset)
Genetic disorder
Glaucoma
Hearing Loss
Heart Disease
High blood pressure
High cholesterol
Inflammatory Bowel
Disease (Crohn’s or
Ulcerative colitis
Hypothyroidism
Hyperthyroidism
Kidney disease
Osteoporosis
Ovarian Cancer
Prostate Cancer
Rheumatoid
Arthritis
Other
Other
Other
Other
Other
Other
Other
Other
Other
Mother Father Sister(s) Brother(s) Mom’s Dad’s Mom’s Dad’s Other
Mom Mom
Dad
Dad
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