Repeat First Name:

Repeat Last Name:

Genetic History
Race: Check all that apply for your ancestors

African American
MotherFatherMGMMGFPGMPGF

Jewish
MotherFatherMGMMGFPGMPGF

Mediterranean
MotherFatherMGMMGFPGMPGF

Hispanic
MotherFatherMGMMGFPGMPGF

Indian (India)
MotherFatherMGMMGFPGMPGF

Southeast Asian
MotherFatherMGMMGFPGMPGF

French Canadian
MotherFatherMGMMGFPGMPGF

Cajun
MotherFatherMGMMGFPGMPGF

Have you or anyone in your family ever been tested positive as a carrier or had any of the following diseases?

Blooms Syndrome
yesno

If yes:
diseasecarriernegativeunknown

Canavan
yesno

If yes:
diseasecarriernegativeunknown

Cystic Fibrosis
yesno

If yes:
diseasecarriernegativeunknown

Fabry Disease
yesno

If yes:
diseasecarriernegativeunknown

Familial Dysautonia
yesno

If yes:
diseasecarriernegativeunknown

Familial Fever
yesno

If yes:
diseasecarriernegativeunknown

Fanconi Anemia
yesno

If yes:
diseasecarriernegativeunknown

Gaucher
yesno

If yes:
diseasecarriernegativeunknown

Niemann-Pick A
yesno

If yes:
diseasecarriernegativeunknown

Mucolipidosis IV
yesno

If yes:
diseasecarriernegativeunknown

Sickle Cell
yesno

If yes:
diseasecarriernegativeunknown

Tay-Sachs
yesno

If yes:
diseasecarriernegativeunknown

Thalassemia
yesno

If yes:
diseasecarriernegativeunknown

Is there anything else we should know about your family?

PERSONAL AND MEDICAL HISTORY
(Please include yourself, mother, father, siblings, grandparents, aunts, uncles, and cousins)

Current allergies (food, pollen, bee stings, medications, etc.):

Childhood allergies you have outgrown:

Medical illnesses, such as asthma, diabetes, seizure disorders, etc.?

Do you have astigmatism (blurred vision due to an irregularity in the curvature of the cornea)?
yesno

If yes, age diagnosed

Do you have any dietary restrictions?

Cancer

(including breast, colon or intestinal, lung, ovarian or uterine, prostate or testicular, skin, stomach, thyroid, blood (e.g. leukemia), other)

Heart

(including stroke, heart attack, heart disease, hardening of arteries, high blood pressure, high cholesterol level):

Blood

(including anemia, sickle-cell anemia, hemophilia or other bleeding problem, blood clots or strokes, leukemia, immune deficiency, lymphoma, HIV, thalassemia, polyarteritis nodosa, other blood disorders):

Respiratory

(including hay fever, asthma, emphysema, tuberculosis, lung cancer, pneumonia, cystic fibrosis, other lung diseases):

Gastro-intestinal

(including appendicitis, ulcer of stomach or duodenum, gall stones, hepatitis A (infectious), hepatitis B (serum), hepatitis C, cirrhosis of the liver, hemochromatosis, other liver diseases, colon cancer, ulcerative colitis, Crohn's disease, pyloric stenosis, rectal disorder, multiple polyps of the colon, inflammatory bowel disease, cystic fibrosis, intestinal cancer, any other problem of the digestive system):

Metabolic/Endocrine

(including diabetes mellitus, childhood diabetes, hypoglycemia, thyroid cancer, thyroid disease, goiter, adrenal dysfunction or disorder, metabolism disorder, hyperactivity, obesity, dwarfism):

Urinary

(including kidney disease, diseases of urinary tract (urethra, bladder, ureter), rectal disorder, polycystic kidneys, kidney stones):

Genital/Reproductive

(including uterine fibroids, hermaphroditism/ambiguous genitals, undescended testicle, hypospodiasis, prostate cancer, ovarian cysts, cancer of ovaries, pelvic inflammatory disease, endometriosis, breast cancer, multiple miscarriages, stillbirths, childhood deaths):

Reproductive Outcomes

(including 2 or more miscarriages, stillborn, premature menopause, death of a newborn infant, childhood death, birth defects, infertility, premature birth):

Neurological

(including migraines, mental retardation, senility before age 50, multiple sclerosis, cerebral palsy, multiple sclerosis, epilepsy, ADD/hyperactivity, autism / asperger’s, hydrocephalus, tuberous sclerosis, disorder of spinal cord, Huntington's chorea, Gaucher's disease, myasthenia gravis, Wilson's disease, Creutzfeldt-Jacob disease, Alzheimer's disease, Parkinson’s disease, neurofibromatosis, scoliosis, Tay Sachs, Canavan disease, tourette’s syndrome, other diseases of nervous system):

Mental Health

(including anxiety/panic attacks, anorexia/bulimia/other eating disorders, schizophrenia, manic depressive, bipolar disorder, alcoholism, drug abuse/misuse/addiction, depression, suicide/attempted suicide, nervous breakdown, mental retardation, criminal convictions, or other disorders requiring hospitalization):

Muscular/Bones/Joints

(including muscular dystrophy, lupus, deformity of spine, osteoporosis, dwarfism growth problem, brittle bones, loss of muscle coordination, marfan syndrome, rheumatoid or juvenile arthritis, spinal muscular atrophy, hereditary low back disease/scoliosis, arthritis, gout, Lupus, Reiter’s disease, myasthenia gravis, other chronic muscle disease):

Sight/Smell/Sound

(including deafness before age 60, deformity of the ear, cataracts before age 50, blindness, color blindness, severe myopia, glaucoma, retinoblastoma, retinitis pigmentosa, deviated septum, any other disorders):

Skin

(including acne, albinism eczema, skin cancer, excessive facial hair (Hirsutism), pigmentation disorders, psoriasis, neurofibromatosis, infectious skin disease, other skin disorders):

Congenital Abnormalities/Birth Defects

(including cleft lip/palate, congenital hip problems, club feet, heart defect, hearing problems, Spina Bifida (open spine), microcephaly, holoprosencehpaly, other):

Chromosomal Abnormalities

(including down syndrome, Turner, Fragile X, other):

Other

(including alcoholism, drug abuse/misuse/addiction, premature degeneration of any organ system, any other condition):

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