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Family Health History
Have any of your close blood relatives (grandparents, parents, brothers, sisters, children) ever had the following?
DiseaseYesNoWhich Relative?Age at DiagnosisHigh Blood PressureHeart DiseaseDiabetesStrokeAsthmaBreast CancerColon or Rectal CancerOther type of Cancer:
Please list_______________Mental Problem
(depression, bipolar, schizophrenia)Alcohol or Drug Problem Other diseases that run in your family: Please list
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