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The Practical Guide to the Genetic Family History - Bennett L.R.

Bennett L.R. The Practical Guide to the Genetic Family History - Wiley-liss, 1999. - 265 p.
ISBN 0-471-22391-3
Download (direct link): thepracticalguidetot1999.pdf
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_Yes _No _Don’t Know
If yes, please explain:_
How many living sisters do you have?_
Do you have any sisters who died? _Yes (list each below) _No
Medical Problem involved in Age at Death Cause of Death the cause of death, if known
Have any of your sisters had any serious health, physical, mental or learningprob-lems?
_Yes _No _Don’t Know
If yes, please explain:_
Do any of your brothers or sisters have a different father or mother? If yes, please indicate which brother or sister, and which parent was different from yours:
YOUR PARENTS
In what year was your mother born?_
Has she had any serious health, physical, mental or learning problems? _Yes_No_Don’t Know
If yes, please explain:_
If she has died, cause of death and age:_
Highest grade she completed in school (circle): 1 2 3 4 5 6 7 8 9 10 11 12 13
14 15 16 17+
Did she receive special education?_Yes _No _Don’t Know
206 SAMPLE ADOPTION MEDICAL-FAMILY HISTORY FORM
Date:_ Medical-Genetic Family Hx (circle): Birth Mother Birth Father Agency#_p. 3 of 8
In what year was your father born?_
Has he had any serious health, physical, mental or learning problems? ___Yes _No_Don’t Know
If yes, please explain:_
If he has died, cause of death and age:_
Highest grade he completed in school (circle): 1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17+
Was he ever in special classes to provide extra help in learning? ___Yes ___ No _Don’t Know
YOUR GRANDPARENTS Your Mother’s Mother:
Has she had any serious health, physical, mental or learning problems? __Yes _No_Don’t Know
If yes, please explain:_
If she has died, cause of death and age:_
Country of origin of her ancestors (for example, Italy, Scotland, etc.):_
Ethnic Background (circle all that apply): White, Jewish, African American, Hispanic
Origin, Native American, Asian, Pacific Islander, Other (Please list):_
Your Mother’s Father:
Has he had any serious health, physical, mental or learning problems?_Yes _
No_Don’t Know
If yes, please explain:_
If he has died, cause of death and age: _
Country of origin of his ancestors (for example, Italy, Scotland, etc.):_
Ethnic Background (circle all that apply): White, Jewish, African American, Hispanic
Origin, Native American, Asian, Pacific Islander, Other (Please list):_
Your Father’s Mother:
Has she had any serious health, physical, mental or learning problems? ___Yes _No_Don’t Know
If yes, please explain:_
If she has died, cause of death and age: _
Country of origin of her ancestors (for example, Italy, Scotland, etc.):_
Ethnic Background (circle all that apply): White, Jewish, African American, Hispanic
Origin, Native American, Asian, Pacific Islander, Other (Please list):_
Your Father’s Father:
Has he had any serious health, physical, mental, or learning problems? ___Yes _No_Don’t Know
If yes, please explain:_
If he has died, cause of death and age:_
Country of origin of his ancestors (for example, Italy, Scotland, etc.):_
Ethnic Background (circle all that apply): White, Jewish, African American, Hispanic Origin, Native American, Asian, Pacific Islander, Other (Please list):
SAMPLE ADOPTION MEDICAL-FAMILY HISTORY FORM 207
Date:_ Medical-Genetic Family Hx (circle): Birth Mother Birth Father Agency#_p. 4 of 8
Genetic-Medical History
Check “Yes” or “No” if you or any of your blood relatives (i.e., your parents, grandparents, aunts, uncles, brothers, sisters, cousins, nieces and nephews) ever had, or now have, any of the medical conditions listed. Include only relatives who are your blood relatives (omit relatives related by marriage or adoption, but include half brothers and half sisters).
Blood How Yourself relative related Specific Medical Conditions Yes No Yes No to you?
1. Blindness or other visual problems (note age affected)
2. Cataracts (note age affected)
3. Glaucoma (note age affected)
4. Deafness, hearing difficulties (note age affected)
5. Unusual shape or missing ear
6. Speech problems
8. Dental problems Example - extra or missing teeth
9. Cleft lip (harelip)
10. Cleft palate
11. Learning disability (slow learner)
12. Mental retardation (estimate severity)
13. Attention deficit disorder and/or hyperactivity
14. Down syndrome
15. Other chromosome abnormality (please specify)
16. Schizophrenia (note age affected)
17. Bipolar depression (note age affected)
If you answered yes to any of the above, please complete the following:
Number Age when first Relationship Comments
(from above) affected to the child (name of disorder if known)
208 SAMPLE ADOPTION MEDICAL-FAMILY HISTORY FORM
Date:_ Medical-Genetic Family Hx (circle): Birth Mother Birth Father Agency#_p. 5 of 8
Blood How Yourself relative related Specific Medical Conditions Yes No Yes No to you?
18. Other mental illness (please specify)
19. Hydrocephalus (water on the brain)
20. Microcephaly (small head)
21. Birthmarks (please describe) Example - unusual shape, size, or number
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