Important Information when Taking Family Genetic History

Generic History
Student's Name
Institutional Affiliation
Course Name
Professor's Name
Due Date
Genetic History Form
Family Member

Description

Paternal grandfather
First and last initials:

SW

Birthdate:

1920

Death date:

2000

Occupation:

Retired as a Fisherman

Education:

unknown

Primary language:

English

Health summary:

Diagnosed with overweight and Obesity, High Blood Pressure, and Diabetes. Died from Diabetes

Paternal grandmother
First and last initials:

CW

Birthdate:

1930

Death date:

1960

Occupation:

Lower Grade Teacher

Education:

Does not want to disclose

Primary language:

English

Health summary:

Diagnosed with Hypertension during her first pregnancy. She died from Preeclampsia in her second pregnancy

Father
First and last initials:

EW

Birthdate:

1955

Death date:

Not Applicable

Occupation:

Registered Dietitian

Education:

Masters Degree

Primary language:

English

Health summary:

He was diagnosed with Hypertension ten years ago. Has been on medication and lifestyle modifications for those years

Father’s siblings (write a summary of any significant health issues)

The father has a brother who is five years younger than him. He was born prematurely following their mother's death. He was born with a heart condition and was diagnosed with Hypertension approximately ten years ago.

Maternal grandfather
First and last initials:

RJ

Birthdate:

1927

Death date:

1997

Occupation:

Retired as a Carpenter

Education:

unknown

Primary language:

English

Health summary:

He was diagnosed with Diabetes secondary to Hypertension. He died from a septic diabetic wound.

Maternal grandmother
First and last initials:

CJ

Birthdate:

1950

Death date:

Not Applicable

Occupation:

Business Woman, operating a grocery store

Education:

Does not want to disclose

Primary language:

English

Health summary:

Fully healthy, without any medical complications

Mother
First and last initials:

RW

Birthdate:

1975

Death date:

Not Applicable

Occupation:

A janitor at a local healthcare facility

Education:

Diploma in public health science

Primary language:

English

Health summary:

Fully Healthy, without any medical complications

Mother’s siblings (write a brief summary of any significant health issues)

Her elder brother was diagnosed with Hypertension recently.

Adult Participant
First and last initials:

KW

Birthdate:

1996

Death date:

Not Applicable

Occupation:

Registered Dietitian

Education:

Bachelor’s Degree in Dietetics and Human Nutrition

Primary language:

English

Health summary:

He was recently diagnosed with Hypertension

Adult participant’s siblings (write a brief summary of any significant health issues)

Other siblings are healthy, without any health issue or complication

Adult participant’s a spouse/significant other
First and last initials:

BW

Birthdate:

1996

Death date:

Not Applicable

Occupation:

House Wife

Education:

University

Primary language:

English

Health summary:

Healthy, without any health issue or complication

Adult participant’s children (write a summary for each child, up to four children)
Child #1 first and last initials:

BW

Birthdate:

2014

Death date:

2014

Occupation:

Not Applicable

Education:

Not Applicable

Primary language:

Not Applicable

Health summary:

Born Prematurely and died from severe birth Asphyxia immediately afte...