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Patient
Family Medical History
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Use this to inform Dr. Tanenbaum of significant medical conditions
of your ancestors, siblings and children.
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Instructions:
This form asks for information about your relative's health
history that will assist us in helping you. Please
be as complete as possible. |
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It will require 10-15 minutes to complete this form.
This form consists of the data entry page below and a
formatted results page for printing. |
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Try
to finish all sections before browsing elsewhere or closing
your browser session. If your session is interrupted
all data will be lost and you will be required to re-enter
it all. This data feature protects your privacy
after you are done. |
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To
navigate use your Browser's "Back" button
to review or make change to a previous page. Use
the "Format" or "Continue"
buttons at the bottom of each page to move forward.
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Please fill out all required* fields so we may
correctly identify you. (terms
of use)
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Family
History 1:
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Except for your spouse, Family refers to blood
or natural relatives.
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Select
your relationship to your spouse and siblings, (brothers
and sisters).
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Check
all items that apply for their present state of
health plus any illnesses they have had.
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Relation:
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Spouse
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Father
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Mother
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Paternal
Relatives
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Maternal
Relatives
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Make
Selections as apply:
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In good Health? |
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Enter
the Number of your Father's or Mother's
Relatives that were affected with each illness:
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or
Poor Health? |
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Deceased** |
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Allergies
or Asthma
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Anemia
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Blood
Clotting Problems
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Diabetes
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Cancer
or Tumor
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Epilepsy
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Glaucoma
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Genetic
Disease
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Alcoholism
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Kidney
or
Bladder Trouble
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Stomach
/ Duodenal Ulcer
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Psychiatric
Disorders
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Rheumatism
or Arthritis
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High
Blood Pressure
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Heart
Disease
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Gout
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Thyroid
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Prostate
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Other
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Describe
Others |
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**Deceased Please indicate specifics of Family
Member deaths |
Relation: Age:
Cause: (Include accidents, suicides, etc.) |
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Family
History 2:
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Select
your relationship to your children and siblings, (sons,
daughters, brothers, sisters).
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Check
all items that apply to their present health
plus any illnesses they have had.
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Check
all items that apply to your present health
and any illnesses you have had.
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Make
Selections as apply: |
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Relation:
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Brothers
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Sisters
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Sons
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Daughters
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Enter
Number of:
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Enter
the Ages of your relatives in years: i.e. 22
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Check
the diseases that have affected your relatives. |
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Allergies
or Asthma
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Anemia
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Blood
Clotting Problems
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Diabetes
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Cancer
or Tumor
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Epilepsy
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Glaucoma
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Genetic
Disease
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Alcoholism
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Kidney
or
Bladder Trouble
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Stomach
/ Duodenal Ulcer
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Psychiatric
Disorders
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Rheumatism
or Arthritis
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High Blood
Pressure
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Heart
Disease
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Gout
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Thyroid
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Prostate
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Other
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Describe
Others
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**Deceased
Please indicate specifics of Family Member
deaths |
Relation: Age:
Cause: (Include accidents, suicides, etc.) |
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Terms
and Conditions:
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agree that I am solely responsible for the security, content,
dissemination by any means and any other use of the information
created by using this electronic form. Further, I hold
Dr. Tanenbaum harmless for any or all consequences resulting
from the dissemination of this information by means not under
his care and control. |
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| I
have read and reviewed this form thoroughly. I accept
the above Terms and Conditions and represent that the information
provided is accurate and complete to the best of my knowledge.
Acknowledge by entering
your full name below. * |
| Signature
of Patient / Legal Guardian |
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Check
Results and Print: |
Click
on "Format" to review and print your completed
form. If you need to make changes use your browser's "Back"
button to return here.
The "Reset" button clears all form data.
All information will be lost. |
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