• Medical Conditions

    Please give information on the medical history of you and any blood relatives, and indicate family member (e.g. your mother, father, sister, brother, aunt, uncle, etc.). Give any additional information that is appropriate such as age at onset, treatment, outcome, etc. If information is unknown ("unk”) or not available ("N/A"), please indicate.
  • YesNo
    Allergies
    Asthma
    Bronchitis
    Emphysema
    Tuberculosis
    Cystic Fibrosis
  • YesNo
    Allergies
    Asthma
    Bronchitis
    Emphysema
    Tuberculosis
    Cystic Fibrosis
  • YesNo
    Ulcers
    Inflammatory Bowel
    Cleft Lip or Palate
    Other
  • YesNo
    Ulcers
    Inflammatory Bowel
    Cleft Lip or Palate
    Other
  • YesNo
    High Blood Pressure
    Heart Attack
    Stroke
    Congestive Heart Failure
    Atherosclerosis
    Heart Rhythm Abnormality
    Congenital Heart Defect
  • YesNo
    High Blood Pressure
    Heart Attack
    Stroke
    Congestive Heart Failure
    Atherosclerosis
    Heart Rhythm Abnormality
    Congenital Heart Defect
  • YesNo
    Mononucleosis
    Hemophilia
    Leukemia
    Lymphomas
    Hodgkin's Disease
    Lupus
  • YesNo
    Mononucleosis
    Hemophilia
    Leukemia
    Lymphomas
    Hodgkin's Disease
    Lupus
  • YesNo
    Kidney Failure / Dialysis / Transplant
    Other Kidney
  • YesNo
    Kidney Failure / Dialysis / Transplant
    Other Kidney
  • YesNo
    Hepatitis (specify)
    Cirrhosis
    Other Liver Disease
  • YesNo
    Hepatitis (specify)
    Cirrhosis
    Other Liver Disease
  • YesNo
    Epilepsy
    Cirrhosis Hydrocephalus
    Multiple Sclerosis
    Huntington's Chorea
    Seizures / Convulsions
  • YesNo
    Epilepsy
    Cirrhosis Hydrocephalus
    Multiple Sclerosis
    Huntington's Chorea
    Seizures / Convulsions
  • YesNo
    Diabetes (Adult or Juvenile)
    Thyroid (Hyper/Hypo)
    Adrenal
  • YesNo
    Diabetes (Adult or Juvenile)
    Thyroid (Hyper/Hypo)
    Adrenal
  • YesNo
    Club Foot
    Scoliosis
    Arthritis (Osteo or Rheumatoid)
    Lupus
  • YesNo
    Club Foot
    Scoliosis
    Arthritis (Osteo or Rheumatoid)
    Lupus
  • YesNo
    Cerebral Palsy
    Muscular Dystrophy
    Spina Bifida
  • YesNo
    Cerebral Palsy
    Muscular Dystrophy
    Spina Bifida
  • YesNo
    Blindness
    Glaucoma
    Cataracts
    Deafness or Other Hearing Problems
  • YesNo
    Blindness
    Glaucoma
    Cataracts
    Deafness or Other Hearing Problems
  • YesNo
    Diagnosed Schizophrenia
    Diagnosed Bi-Polar
    Other Mental Illness (Describe)
  • YesNo
    Diagnosed Schizophrenia
    Diagnosed Bi-Polar
    Other Mental Illness (Describe)
  • YesNo
    Cancer
    Tumors
    Cystic Fibrosis
    Hodgkins Disease
  • YesNo
    Cancer
    Tumors
    Cystic Fibrosis
    Hodgkins Disease
  • YesNo
    a. Prescription Drugs
  • NameWhenHow OftenAmount 
    Click on + button to add more than one
  • YesNo
    a. Non-Prescription Drugs (include asprin, nosedrops, etc)
  • NameWhenHow OftenAmount 
    Click on + button to add more than one
  • c. Alcohol and other substances
  • YesNo
    1. Alcohol (wine, beer, etc)
  • WhenHow OftenAmount
  • YesNo
    2. Amphetamines (uppers)
  • WhenHow OftenAmount
  • YesNo
    3. Barbiturates (downers)
  • WhenHow OftenAmount
  • YesNo
    4. Tobacco
  • WhenHow OftenAmount
  • YesNo
    5. Cocaine
  • WhenHow OftenAmount
  • YesNo
    6. Crack
  • WhenHow OftenAmount
  • YesNo
    7. Heroin
  • WhenHow OftenAmount
  • YesNo
    8. LSD
  • WhenHow OftenAmount
  • YesNo
    9. PCP
  • WhenHow OftenAmount
  • YesNo
    10. Marijuana
  • WhenHow OftenAmount
  • YesNo
    11. Other (specify)
  • WhenHow OftenAmount