For the symptoms above provide any details you feel are relevant and important.
Any other major conditions not listed here? Or any long-term effects of the above symptoms?
List any surgeries or medical procedures & dates:
Indicate if there is/was any ailment or illness that affects more family members than you were able to indicate in the above form. List details here.
Any other major ailments not listed here? List person and condition:
Any losses or major accidents that have had a great impact on your family?
