How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
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- Christopher Robbins
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1 Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We are looking for your own answers, and not what you think your doctors, family, or friends want you to say. Don t feel like you have to spend a long time on each question. The first answer that comes to you is usually the best one. If you aren t sure how to answer a question, choose the best answer from the available choices. Some questions also let you say if you don t know an answer, or would rather not answer. This module asks you about your family s medical history. You will be shown a list of conditions and asked to select those that certain family members have or had. Understanding your family s experiences with medical issues can tell us a lot about what kinds of medical issues might be related to your genetics. Genetics has to do with traits that are passed down from generation to generation in a family. You will be asked questions about your family. Think only of people you are related to by blood including those living or deceased. How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all Branching logic: Display following questions if A lot or Some ; End survey if None at all Please indicate if your mother has ever been diagnosed with the following health conditions and/or health events. Think only of the person you are related to by blood. (select all that apply) 1 Cancer: o Bladder cancer o Bone cancer o Blood or soft tissue cancer o Brain cancer o Breast cancer o Cervical cancer o Colon cancer/rectal cancer o Endocrine cancer o Endometrial cancer 1
2 o Esophageal cancer o Eye cancer o Head and neck (This includes cancers of the mouth, sinuses, nose, or throat. This does not include brain cancer.) o Kidney cancer o Lung cancer o Ovarian cancer o Pancreatic cancer o Skin cancer o Stomach cancer o Thyroid cancer o Other cancer (Please specify: (free text answer)) Heart and blood conditions: o Anemia o Aortic aneurysm o Atrial fibrillation (or a-fib) or atrial flutter (or a-flutter). o Congestive heart failure o Coronary artery/coronary heart disease (included angina) o Heart attack o Heart valve disease o High blood pressure (Hypertension) o High cholesterol o Peripheral vascular disease o Pulmonary embolism or deep vein thrombosis (DVT) o Sickle cell disease o Stroke o Sudden death Digestive conditions: o Acid reflux o Celiac disease o Colon polyps o Crohn's disease o Diverticulitis/Diverticulosis o Gall stones o Irritable bowel syndrome (IBS) o Peptic (stomach) ulcers o Ulcerative colitis Hormone/endocrine conditions: o Hyperthyroidism o Hypothyroidism o Type 1 diabetes o Type 2 diabetes 2
3 o Other/unknown diabetes Kidney conditions: o Kidney disease o Kidney stones Lung conditions: o Asthma o Chronic lung disease (COPD, emphysema or bronchitis) o Sleep apnea Brain and nervous system conditions: o Dementia (includes Alzheimer's, vascular, etc.) o Epilepsy or seizure o Lou Gehrig s disease (Amyotrophic lateral sclerosis) o Migraine headaches o Multiple sclerosis o Muscular dystrophy (MD) o Narcolepsy o Neuropathy o Parkinson's disease o Restless leg syndrome Mental health or substance use of conditions: o Alcohol use disorder o Anxiety reaction/panic disorder o Autism spectrum disorder o Bipolar disorder o Depression o Drug use disorder o Schizophrenia Bone, joint and muscle conditions: o Fibromyalgia o Gout o Osteoarthritis o Osteoporosis o Pseudogout (CPPD) o Rheumatoid arthritis o Systemic lupus o Spine, muscle, or bone disorders (non-cancer) Hearing and eye conditions: o Cataracts o Glaucoma o Macular degeneration o Severe hearing loss or partial deafness in one or both ears Other conditions: o Allergies 3
4 o Endometriosis o Fibroids o Obesity o Polycystic ovarian syndrome o Reactions to anesthesia (such as hyperthermia) o Skin condition (e.g., eczema, psoriasis) o Other: [FREE TEXT] None of the above Don t know Prefer not to answer Please indicate if your father has ever been diagnosed with the following health conditions and/or health events. Think only of the person you are related to by blood. (select all that apply) 1 Cancer: o Bladder cancer o Bone cancer o Blood or soft tissue cancer o Brain cancer o Breast cancer o Colon cancer/rectal cancer o Endocrine cancer o Esophageal cancer o Eye cancer o Head and neck (This includes cancers of the mouth, sinuses, nose, or throat. This does not include brain cancer.) o Kidney cancer o Lung cancer o Pancreatic cancer o Prostate cancer o Skin cancer o Stomach cancer o Thyroid cancer o Other cancer (Please specify: (free text answer)) Heart and blood conditions: o Anemia o Aortic aneurysm o Atrial fibrillation (or a-fib) or atrial flutter (or a-flutter). o Congestive heart failure o Coronary artery/coronary heart disease (included angina) o Heart attack o Heart valve disease 4
5 o High blood pressure (Hypertension) o High cholesterol o Peripheral vascular disease o Pulmonary embolism or deep vein thrombosis (DVT) o Sickle cell disease o Stroke o Sudden death Digestive conditions: o Acid reflux o Celiac disease o Colon polyps o Crohn's disease o Diverticulitis/Diverticulosis o Gall stones o Irritable bowel syndrome (IBS) o Peptic (stomach) ulcers o Ulcerative colitis Hormone/endocrine conditions: o Hyperthyroidism o Hypothyroidism o Type 1 diabetes o Type 2 diabetes o Other/unknown diabetes Kidney conditions: o Kidney disease o Kidney stones Lung conditions: o Asthma o Chronic lung disease (COPD, emphysema or bronchitis) o Sleep apnea Brain and nervous system conditions: o Dementia (includes Alzheimer's, vascular, etc.) o Epilepsy or seizure o Lou Gehrig s disease (Amyotrophic lateral sclerosis) o Migraine headaches o Multiple sclerosis o Muscular dystrophy (MD) o Narcolepsy o Neuropathy o Parkinson's disease o Restless leg syndrome Mental Health or substance use of conditions: 5
6 o Alcohol use disorder o Anxiety reaction/panic disorder o Autism spectrum disorder o Bipolar disorder o Depression o Drug use disorder o Schizophrenia Bone, joint and muscle conditions: o Fibromyalgia o Gout o Osteoarthritis o Osteoporosis o Pseudogout (CPPD) o Rheumatoid arthritis o Systemic lupus o Spine, muscle, or bone disorders (non-cancer) Hearing and eye conditions: o Cataracts o Glaucoma o Macular degeneration o Severe hearing loss or partial deafness in one or both ears Other conditions: o Allergies o Obesity o Reactions to anesthesia (such as hyperthermia) o Skin condition (e.g., eczema, psoriasis) o Other: [FREE TEXT] None of the above Don t know Prefer not to answer Please indicate if your brothers and/or sisters [people with the same mother and/or father as you] have ever been diagnosed with the following health conditions and/or health events. Think only of those people you are related to by blood. If you have more than one brother or sister, check the box if any of your brothers or sisters have the condition (select all that apply) 1 Cancer: o Bladder cancer o Bone cancer o Blood or soft tissue cancer o Brain cancer o Breast cancer 6
7 o Cervical cancer o Colon cancer/rectal cancer o Endocrine cancer o Endometrial cancer o Esophageal cancer o Eye cancer o Head and neck (This includes cancers of the mouth, sinuses, nose, or throat. This does not include brain cancer.) o Kidney cancer o Lung cancer o Ovarian cancer o Pancreatic cancer o Prostate cancer o Skin cancer o Stomach cancer o Thyroid cancer o Other cancer (Please specify: (free text answer)) Heart and blood conditions: o Anemia o Aortic aneurysm o Atrial fibrillation (or a-fib) or atrial flutter (or a-flutter). o Congestive heart failure o Coronary artery/coronary heart disease (included angina) o Heart attack o Heart valve disease o High blood pressure (Hypertension) o High cholesterol o Peripheral vascular disease o Pulmonary embolism or deep vein thrombosis (DVT) o Sickle cell disease o Stroke o Sudden death Digestive conditions: o Acid reflux o Celiac disease o Colon polyps o Crohn's disease o Diverticulitis/Diverticulosis o Gall stones o Irritable bowel syndrome (IBS) o Peptic (stomach) ulcers o Ulcerative colitis 7
8 Hormone/endocrine conditions: o Hyperthyroidism o Hypothyroidism o Type 1 diabetes o Type 2 diabetes o Other/unknown diabetes Kidney conditions: o Kidney disease o Kidney stones Lung conditions: o Asthma o Chronic lung disease (COPD, emphysema or bronchitis) o Sleep apnea Brain and nervous system conditions: o Dementia (includes Alzheimer's, vascular, etc.) o Epilepsy or seizure o Lou Gehrig s disease (Amyotrophic lateral sclerosis) o Migraine headaches o Multiple sclerosis o Muscular dystrophy (MD) o Narcolepsy o Neuropathy o Parkinson's disease o Restless leg syndrome Mental health or substance use of conditions: o Alcohol use disorder o Anxiety reaction/panic disorder o Autism spectrum disorder o Bipolar disorder o Depression o Drug use disorder o Schizophrenia Bone, joint and muscle conditions: o Fibromyalgia o Gout o Osteoarthritis o Osteoporosis o Pseudogout (CPPD) o Rheumatoid arthritis o Systemic lupus o Spine, muscle, or bone disorders (non-cancer) Hearing and eye conditions: o Cataracts 8
9 o Glaucoma o Macular degeneration o Severe hearing loss or partial deafness in one or both ears Other conditions: o Allergies o Endometriosis o Fibroids o Obesity o Polycystic ovarian syndrome o Reactions to anesthesia (such as hyperthermia) o Skin condition (e.g., eczema, psoriasis) o Other: [FREE TEXT] None of the above Don t know Prefer not to answer I do not have any brothers or sisters related by blood. Please indicate if your daughter(s) has/have ever been diagnosed with the following health conditions and/or health events. Think only of those people you are related to by blood. (select all that apply) 1 Cancer: o Bladder cancer o Bone cancer o Blood or soft tissue cancer o Brain cancer o Breast cancer o Cervical cancer o Colon cancer/rectal cancer o Endocrine cancer o Endometrial cancer o Esophageal cancer o Eye cancer o Head and neck (This includes cancers of the mouth, sinuses, nose, or throat. This does not include brain cancer.) o Kidney cancer o Lung cancer o Ovarian cancer o Pancreatic cancer o Skin cancer o Stomach cancer o Thyroid cancer 9
10 o Other cancer (Please specify: (free text answer)) Heart and blood Conditions: o Anemia o Aortic aneurysm o Atrial fibrillation (or a-fib) or atrial flutter (or a-flutter). o Congestive heart failure o Coronary artery/coronary heart disease (included angina) o Heart attack o Heart valve disease o High blood pressure (Hypertension) o High cholesterol o Peripheral vascular disease o Pulmonary embolism or deep vein thrombosis (DVT) o Sickle cell disease o Stroke o Sudden death Digestive conditions: o Acid reflux o Celiac disease o Colon polyps o Crohn's disease o Diverticulitis/Diverticulosis o Gall stones o Irritable bowel syndrome (IBS) o Peptic (stomach) ulcers o Ulcerative colitis Hormone/endocrine conditions: o Hyperthyroidism o Hypothyroidism o Type 1 diabetes o Type 2 diabetes o Other/unknown diabetes Kidney conditions: o Kidney disease o Kidney stones Lung conditions: o Asthma o Chronic lung disease (COPD, emphysema or bronchitis) o Sleep apnea Brain and nervous system conditions: o Dementia (includes Alzheimer's, vascular, etc.) o Epilepsy or seizure 10
11 o Lou Gehrig s disease (Amyotrophic lateral sclerosis) o Migraine headaches o Multiple sclerosis o Muscular dystrophy (MD) o Narcolepsy o Neuropathy o Parkinson's disease o Restless leg syndrome Mental health or substance use of conditions: o Alcohol use disorder o Anxiety reaction/panic disorder o Autism spectrum disorder o Bipolar disorder o Depression o Drug use disorder o Schizophrenia Bone, joint and muscle conditions: o Fibromyalgia o Gout o Osteoarthritis o Osteoporosis o Pseudogout (CPPD) o Rheumatoid arthritis o Systemic lupus o Spine, muscle, or bone disorders (non-cancer) Hearing and eye conditions: o Cataracts o Glaucoma o Macular degeneration o Severe hearing loss or partial deafness in one or both ears Other conditions: o Allergies o Endometriosis o Fibroids o Obesity o Polycystic ovarian syndrome o Reactions to anesthesia (such as hyperthermia) o Skin condition (e.g., eczema, psoriasis) o Other: [FREE TEXT] None of the above Don t know Prefer not to answer 11
12 I do not have any daughters related by blood. Please indicate if your son(s) has/have ever been diagnosed with the following health conditions and/or health events. Think only of the person you are related to by blood. (select all that apply) 1 Cancer: o Bladder cancer o Bone cancer o Blood or soft tissue cancer o Brain cancer o Breast cancer o Colon cancer/rectal cancer o Endocrine cancer o Esophageal cancer o Eye cancer o Head and neck (This includes cancers of the mouth, sinuses, nose, or throat. This does not include brain cancer.) o Kidney cancer o Lung cancer o Pancreatic cancer o Prostate cancer o Skin cancer o Stomach cancer o Thyroid cancer o Other cancer (Please specify: (free text answer)) Heart and blood conditions: o Anemia o Aortic aneurysm o Atrial fibrillation (or a-fib) or atrial flutter (or a-flutter). o Congestive heart failure o Coronary artery/coronary heart disease (included angina) o Heart attack o Heart valve disease o High blood pressure (Hypertension) o High cholesterol o Peripheral vascular disease o Pulmonary embolism or deep vein thrombosis (DVT) o Sickle cell disease o Stroke o Sudden death Digestive conditions: o Acid reflux 12
13 o Celiac disease o Colon polyps o Crohn's disease o Diverticulitis/Diverticulosis o Gall stones o Irritable bowel syndrome (IBS) o Peptic (stomach) ulcers o Ulcerative colitis Hormone/endocrine conditions: o Hyperthyroidism o Hypothyroidism o Type 1 diabetes o Type 2 diabetes o Other/unknown diabetes Kidney conditions: o Kidney disease o Kidney stones Lung conditions: o Asthma o Chronic lung disease (COPD, emphysema or bronchitis) o Sleep apnea Brain and nervous system conditions: o Dementia (includes Alzheimer's, vascular, etc.) o Epilepsy or seizure o Lou Gehrig s disease (Amyotrophic lateral sclerosis) o Migraine headaches o Multiple sclerosis o Muscular dystrophy (MD) o Narcolepsy o Neuropathy o Parkinson's disease o Restless leg syndrome Mental health or substance use of conditions: o Alcohol use disorder o Anxiety reaction/panic disorder o Autism spectrum disorder o Bipolar disorder o Depression o Drug use disorder o Schizophrenia Bone, joint and muscle conditions: o Fibromyalgia 13
14 o Gout o Osteoarthritis o Osteoporosis o Pseudogout (CPPD) o Rheumatoid arthritis o Systemic lupus o Spine, muscle, or bone disorders (non-cancer) Hearing and eye conditions: o Cataracts o Glaucoma o Macular degeneration o Severe hearing loss or partial deafness in one or both ears Other conditions: o Allergies o Obesity o Reactions to anesthesia (such as hyperthermia) o Skin condition (e.g., eczema, psoriasis) o Other: [FREE TEXT] None of the above Don t know Prefer not to answer I do not have any sons related by blood. Please indicate if your grandparent(s) have ever been diagnosed with the following health conditions and/or health events. Think only of those people you are related to by blood. (select all that apply) 1 Cancer: o Bladder cancer o Bone cancer o Blood or soft tissue cancer o Brain cancer o Breast cancer o Cervical cancer o Colon cancer/rectal cancer o Endocrine cancer o Endometrial cancer o Esophageal cancer o Eye cancer o Head and neck (This includes cancers of the mouth, sinuses, nose, or throat. This does not include brain cancer.) o Kidney cancer 14
15 o Lung cancer o Ovarian cancer o Pancreatic cancer o Prostate cancer o Skin cancer o Stomach cancer o Thyroid cancer o Other cancer (Please specify: (free text answer)) Heart and blood conditions: o Anemia o Aortic aneurysm o Atrial fibrillation (or a-fib) or atrial flutter (or a-flutter). o Congestive heart failure o Coronary artery/coronary heart disease (included angina) o Heart attack o Heart valve disease o High blood pressure (Hypertension) o High cholesterol o Peripheral vascular disease o Pulmonary embolism or deep vein thrombosis (DVT) o Sickle cell disease o Stroke o Sudden death Digestive conditions: o Acid reflux o Celiac disease o Colon polyps o Crohn's disease o Diverticulitis/Diverticulosis o Gall stones o Irritable bowel syndrome (IBS) o Peptic (stomach) ulcers o Ulcerative colitis Hormone/endocrine conditions: o Hyperthyroidism o Hypothyroidism o Type 1 diabetes o Type 2 diabetes o Other/unknown diabetes Kidney conditions: o Kidney disease o Kidney stones 15
16 Lung Conditions: o Asthma o Chronic lung disease (COPD, emphysema or bronchitis) o Sleep apnea Brain and nervous system conditions: o Dementia (includes Alzheimer's, vascular, etc.) o Epilepsy or seizure o Lou Gehrig s disease (Amyotrophic lateral sclerosis) o Migraine headaches o Multiple sclerosis o Muscular dystrophy (MD) o Narcolepsy o Neuropathy o Parkinson's disease o Restless leg syndrome Mental health or substance use of conditions: o Alcohol use disorder o Anxiety reaction/panic disorder o Autism spectrum disorder o Bipolar disorder o Depression o Drug use disorder o Schizophrenia Bone, joint and muscle conditions: o Fibromyalgia o Gout o Osteoarthritis o Osteoporosis o Pseudogout (CPPD) o Rheumatoid arthritis o Systemic lupus o Spine, muscle, or bone disorders (non-cancer) Hearing and eye conditions: o Cataracts o Glaucoma o Macular degeneration o Severe hearing loss or partial deafness in one or both ears Other conditions: o Allergies o Endometriosis o Fibroids o Obesity 16
17 o Polycystic ovarian syndrome o Reactions to anesthesia (such as hyperthermia) o Skin condition (e.g., eczema, psoriasis) Other: [FREE TEXT] None of the above Don t know Prefer not to answer Thank you for completing the Family Medical History survey. The information you have shared may contribute to helping researchers improve the health of generations to come. Sources 1. Developed for use in All of Us. 17
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