FAMILY HISTORY (1) NAME:_________________________
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YOUR FATHER |
HIS FATHER |
HIS MOTHER |
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LAST NAME |
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FIRST NAME |
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BIRTH DATE (88=dont know) |
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DEATH DATE (11 = alive) |
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AGE |
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CAUSE OF DEATH |
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STATE OF DEATH KY=Kentucky 77=outside USA |
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(check = yes) |
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MEMORY PROBLEM |
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SENILITY |
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DEMENTIA |
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ALZHEIMER'S DISEASE |
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STROKE |
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HEAD INJURY |
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UNCONSCIOUSNESS |
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SKULL FRACTURE |
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PARKINSON'S DISEASE |
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NERVES |
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MENTAL ILLNESS |
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DEPRESSION |
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ALCOHOLISM |
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LIST OTHER MEDICAL CONDITIONS |
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FAMILY HISTORY (2) NAME:_________________________
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YOUR MOTHER |
HER FATHER |
HER MOTHER |
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LAST NAME |
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FIRST NAME |
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BIRTH DATE (88=dont know) |
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DEATH DATE (11 = alive) |
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AGE |
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CAUSE OF DEATH |
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STATE OF DEATH KY=Kentucky 77=outside USA |
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(check = yes) |
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MEMORY PROBLEM |
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SENILITY |
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DEMENTIA |
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ALZHEIMER'S DISEASE |
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STROKE |
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HEAD INJURY |
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UNCONSCIOUSNESS |
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SKULL FRACTURE |
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PARKINSON'S DISEASE |
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NERVES |
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MENTAL ILLNESS |
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DEPRESSION |
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ALCOHOLISM |
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LIST OTHER MEDICAL CONDITIONS |
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FAMILY HISTORY (3) NAME:_________________________
LIST SIBLINGS IN ORDER OF BIRTH (BROTHERS, SISTERS), OLDEST FIRST
FILL IN A "*" FOR YOURSELF
FOR SEX: M = MALE (BROTHER); F = FEMALE (SISTER)
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NAME |
SAME FATHER -CHECK |
SAME MOTHER -CHECK |
SEX |
BIRTH DATE |
DEATH DATE 1=alive |
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1 |
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2 |
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3 |
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4 |
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5 |
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6 |
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7 |
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8 |
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9 |
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10 |
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11 |
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12 |
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LIST SIBLING'S # AFFECTED BY DISEASES DIAGNOSED BY A DOCTOR
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SIBLING #'S (FROM ABOVE) |
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DIABETES |
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HYPERTENSION |
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HEART DISEASE |
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POOR MEMORY |
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SENILITY |
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ALZHEIMER'S |
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STROKE |
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DEPRESSION |
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NERVES |
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ALCOHOLISM |
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MONGOLISM |
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FAMILY HISTORY (4) NAME:_________________________
PLEASE LIST OTHER FAMILY RELATIVES WHO MAY HAVE HAD:
DEMENTIA
ALZHEIMER'S DISEASE
SENILITY, AND SO FORTH
INCLUDING AUNTS, UNCLES, GREAT GRANDPARENTS, GREAT AUNTS, UNCLES