Please answer the following questions pertaining to mental health history:
Please complete the table below to indicate whether you or any of your immediate family members (mother, father, brother, sister, grandmother, grandfather, aunt, uncle, or children) currently have or have had any of the following medical conditions in the past.
For any of the following conditions where you select a ‘Yes’ response, please use the fields provided to indicate who currently has (or has had in the past) the specific medical condition, the age of onset for the condition, and whether any medications were prescribed for the condition. Please be as specific as possible. Below are a few examples.
- I am a carrier of Sickle Cell Disease. I found this out in 2019 when I donated blood.
- My son has had milk intolerance since birth. He is healthy as long as he maintains a dairy-free diet.
- My sister has asthma and was diagnosed with it when she was 10. She uses a ProAir Inhaler.
- My grandfather died of a heart attack at age 75. He smoked 2 packs of cigarettes every day for 30 years.
If you or any members of your immediate family have any other medical conditions or diseases that are not on this list, please use the space below to let us know what they are.