1 Survey

Appendix A A.2.1.d–10

Family Medical

History Questionnaire

Instructions

Please complete the Family Medical History questionnaire as best as you can. If you don’t know the answer to one or more questions or have the information you need to complete the questionnaire, please don’t guess. Instead, please contact your biological mother, father, or full brothers and sisters and ask them to help you complete the questionnaire. If you need help or have questions while completing this questionnaire, please call XXX-XXX-XXXX.

The following questions are about your parents and siblings, not your children.

1. Were you raised by your biological parent or parents, adoptive parents, foster parents, or other relatives? (MARK ALL THAT APPLY.)

• Biological parent(s)  Q3

• Adoptive parent(s)

• Foster parent(s)

• Other relatives, specify: ______________________________

• Don’t know

2. Do you know anything about the health conditions of your biological relatives?

• Yes

• No  END

• Don’t know

3. How many full siblings do you have? By full sibling, we mean brothers or sisters you have with the same biological mother and father.

|___|___|

NUMBER OF FULL SIBLINGS

• No siblings

• Don’t know

4. Is your biological mother still living?

• Yes  Q7

• No

• Don’t know  Q7

5. What was the cause of her death?

____________________________________

MOTHER’S CAUSE OF DEATH

• Don’t know

6. How old was she when she died? If you aren’t sure how old she was when she died, please guess as closely as you can.

|___|___|___|

AGE

• Don’t know

7. Is your biological father still living?

• Yes  Q10

• No

• Don’t know  Q10

8. What was the cause of his death?

____________________________________

FATHER’S CAUSE OF DEATH

• Don’t know

9. How old was he when he died? If you aren’t sure how old he was when he died, please guess as closely as you can.

|___|___|___|

AGE

• Don’t know

Please answer the following questions about your biological mother and father, as well as any full brothers and/or sisters you have.

	Mother	Father	Full Brother/Sister # 1
Heart attack?	Y es No Don’t know Did she have a heart attack before age 55? Yes No Don’t know	Y es No Don’t know Did he have a heart attack before age 55? Yes No Don’t know	Y es No Don’t know Did s/he have a heart attack before age 55? Yes No Don’t know
Angioplasty or coronary bypass surgery?	Y es No Don’t know Did she have angioplasty or coronary bypass surgery before age 55? Yes No Don’t know	Y es No Don’t know Did he have angioplasty or coronary bypass surgery before age 55? Yes No Don’t know	Y es No Don’t know Did s/he have angioplasty or coronary bypass surgery before age 55? Yes No Don’t know
Asthma?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Eczema or atopic dermatitis?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Allergies?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
High blood pressure?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know

	Mother	Father	Full Brother/Sister # 1
Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Autism, Asperger syndrome or other autism spectrum disorder?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
An eating disorder such as anorexia or bulimia?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Alcoholism?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Bipolar disorder?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Depression other than bipolar disorder?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Schizophrenia?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Anxiety disorder such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?	Y es No Don’t know What type of anxiety disorder was she diagnosed with: ________________________	Y es No Don’t know What type of anxiety disorder was he diagnosed with: ________________________	Y es No Don’t know What type of anxiety disorder was s/he diagnosed with: ________________________
Mental retardation?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know

	Full Brother/Sister # 2	Full Brother/Sister # 3	Full Brother/Sister # 4
Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Autism, Asperger syndrome or other autism spectrum disorder?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
An eating disorder such as anorexia or bulimia?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Alcoholism?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Bipolar disorder?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Depression other than bipolar disorder?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Schizophrenia?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
Anxiety disorder such as generalized anxiety disorder (GAD) or obsessive compulsive disorder (OCD)?	Y es No Don’t know What type of anxiety disorder was s/he diagnosed with: ________________________	Y es No Don’t know What type of anxiety disorder was s/he diagnosed with: ________________________	Y es No Don’t know What type of anxiety disorder was s/he diagnosed with: ________________________
Mental retardation?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know