FAMILY HISTORY: Please list immediate family members with a history of any of the following:
Anemia________________________
Asthma________________________
Autism________________________
Alcoholism_____________________
Allergies_______________________
Arthritis________________________
Bleeding Disorder________________________
Bed-wetting________________________
Blood problems_________________
Cancer__________________________
Celiac disease________________________
Diabetes_______________________
Deafness_______________________
Drug abuse_______________________
Died suddenly under age 50_______________________
Epilepsy or convulsion_______________________
GI problems____________________
Hepatitis_______________________
High cholesterol_________________
High blood pressure______________
Heart Disease______________
High Cholesterol______________
Seizures_______________________
Heart disease___________________
Immune problems___________________
Kidney problems________________
Liver Disease___________________
Lung problems__________________
Migraines_______________________
Mental retardation_______________
Mental illness_______________
Obesity________________________
Prolonged QT Syndrome_______________
Stroke__________________________
Skin problems___________________
Tuberculosis___________________________
Thyroid problems_______________
Other___________________________