HISTORY
1.
Mark which of your blood relatives or spouse you are SURE have
experienced any of the following:
ec
ud
=
th
o
=
WY
ef
=
oF
<<
we
iu
td
= =
RO
oOo <
=
ae
WY
“Y
WY
Lud
tu
xc
ff
ef
ef
lu
hu
Lid
tat
=
=
= =
Ee
Fe
Fe
F&F
oatoo
=
un.
=
=
°
{om
~_
—N
as
bod
oc
ty
x
tut
oe
=
Y
©
=>
—
Ke
bis
Lis
=
=
F&F
KF
<
«
ee
te
_—
oc
co
co
Y
u
~~
WA
—
_—
Ww
—
-_"
~
tau
“4
<=
oS
<x
co
So
Qa
“
>
a.
wr
Diabetes (sugar)
Stroke
Heart Attack
Epilepsy (convulsions, 7
ct
w
~~
High blood pressure |
Kidney disease
Cancer
Mental Retardation
Hay fever, asthma, hives, allergy
Emphysema
Thyroid or goiter trouble
Bleeding or blood trouble
Gout (a kind of arthritis)
Mental disorder, nervous breakdown
Suicide
3
EZ
EB
ye
a
re
fk
Gf.
~
xm
ew.
je
~—
_—
lle
ra
Ed
ja.
a