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FAMILY HISTORY / ILLNESS

PLEASE MARK ANY MAJOR MEDICAL CONDITIONS THAT RUN IN YOUR FAMILY, BE SURE TO INDICATE YOUR RELATIONSHIP TO THAT PERSON.

CONDITION ASTHMA ARTHRITIS CANCER CEREBRAL PALSY DEMENTIA/ALZHEIMER’S DIABETES EPILEPSY/SEIZURES HEADACHES/MIGRAINES HEART ATTACK/DISEASE HIGH BLOOD PRESSURE MENTAL ILLNESS MENTAL RETARDATION MUSCLE DISEASE SICKLE CELL DISEASE STROKE THYROID DISEASE

RELATIVE

IMMEDIATE FAMILY

RELATIVE FATHER

AGE

HEALTH ISSUES

LIVING

CAUSE OF DEATH

MOTHER SIBLINGS

SPOUSE CHILDREN

COMMENTS:

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