Family History
Child’s name: ____________________
Date of Birth: _______
Today’s Date: ____________________
We are interested in the medical histories of:
- your child’s brothers and sisters
- you and your spouse (or child’s biologic parent)
- your brothers, sisters and parents
(The family histories of your cousins and grandparents is less relevant.)
Neurologic: |
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Seizures |
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Mental retardation |
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Learning disability/dyslexia |
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ADHD |
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Hearing problems |
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Endocrine: |
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Thyroid disease |
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Diabetes - child onset |
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Diabetes - adult onset |
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Obesity |
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Allergic: |
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Asthma |
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Hay fever/Allergies |
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Food Allergies |
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Cardiovascular: |
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Heart disease before age 60 |
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High cholesterol |
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High blood pressure |
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Psychiatric: |
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Depression |
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Suicide |
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Drug/Alcohol abuse |
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Panic attacks |
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Eating disorder |
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Other: