NR305 Family Genetic History Form Agapi

Family Genetic History Form
Your Name: Irina Agapi Date: 3/20/2014
Your Instructor’s Name: Prof. Felicia Butler
1: Family Genetic History (35 points):
Complete the family genetic history form below. Indicate if any information is N/A (not applicable) or unknown. Indicate any information the person did not want to disclose by noting “Does not want to disclose.”
Family Member
Description
Paternal grandfather
First and last initials:
L.M.
Birthdate:
1900
Death date:
1995
Occupation:
Shopkeeper
Education:
High School
Primary language:
English
Health summary:
Dementia. Died of a stroke.
Paternal grandmother
First and last initials:
W.M.
Birthdate:
1905
Death date:
2000
Occupation:
Homemaker
Education:
High School
Primary language:
English
Health summary:
R. leg BKA amputation, diagnosed with lung disease. Died of unknown cause, possible MI. She was found in the morning not breathing.
Father
First and last initials:
BM
Birthdate:
10/27/1935
Death date:
Alive
Occupation:
Retired from BA as a Marketing Director
Education:
Bachelor degree
Primary language:
English
Health summary:
HTN, Melanoma, CABG and MI at age 60.
Father’s siblings (write a brief summary of any significant health issues)
None
Maternal grandfather
First and last initials:
G.F.
Birthdate:
1900
Death date:
1990
Occupation:
Lt. Colonel in the British Army
Education:
Military College
Primary language:
Scottish
Health summary:
Arthritis. Died of a stroke.
Maternal grandmother
First and last initials:
P.F.
Birthdate:
1906
Death date:
1980
Occupation:
Homemaker
Education:
High School
Primary language:
English
Health summary:
Smoker, COPD. Died of a stroke.
Mother
First and last initials:
G. M.
Birthdate:
1/15/1935
Death date:
Alive
Occupation:
Homemaker
Education:
High School
Primary language:
English
Health summary:
Bilateral Hip Replacement
Mother’s siblings (write a brief summary of any significant health issues)
None
Adult Participant
First and last initials:
C.M.
Birthdate:
08/06/1971