Appendix A Genetic Family history form Date: 01/19/2022 Date of Birth: 09/XX/1969

Appendix A
Genetic Family history form
Date: 01/19/2022
Date of Birth: 09/XX/1969 Sex: Female Ethnicity: White
Address: West Palm Beach, Florida
Phone number: 561-XXX-XXXX Work number: N/A
Occupation: Project Manager Highest Grade Completed: MBA
Name of spouse: N/A
Date of Birth:01/XX/1982
Referring doctor: Dr. A.O
Address: West Palm Beach, Florida
Family doctor: Dr. E.B
Address: West Palm Beach, Florida
Reason for Referral: Numbness and Tingling to the right side of the body . (Second Opinion)
Medical Diagnosis (if known): N/A
List any Health Problem you (the patient): Krabbe’s disease gene carrier, Alpha Thalassemia
Name and Location
Reason
Date
Palm West Regional
Cholecystectomy
08/13/2019
Palm West Regional
Right Knee Arthroplasty
02/18/2015
List any Hospitalization (Place, Reason & date): Palm West Regional – Cholecystectomy 08/13/2019
Palm West Regional – Right Knee Arthroplasty, 02/18/2015
The Index Patient’s Brothers/Sisters and their Children
List your brothers/sister. Please include stillbirths(sb), miscarriage(m), and those deceased(d).
Name of Sibling
Date of birth month/year
Sex
Present Health
Sibling’s Children
List age & sex
T. A
02/1977
M
HTN
2
T. J/(M)10 & L. J/(F)13
C.A
06/1989- 02/1981
F
Deceased/Died of Krabbe’s disease
N/A
N/A
Are any of the above half-brothers/sisters and/or stepbrothers/sisters? N/A
Are any of the above adopted or foster children? N/A
Biological Mother of Index Patient
Name: K. A Maiden (family) name: P
Date and place of birth: 07/1953, Iowa Ethnic origin: White
Present health Hypertension & Krabbe’s disease gene carrier (if deceased, date, and cause of death) deceased at the age of from complications N/A
Mother’s Brother and sisters and their Children
Include stillbirths(sb), miscarriages(m), deceased(d)
Name of Sibling
Date of birth month/year
Sex
Present Health
Sibling’s Children
List age & sex
J. P
03/1957
M
Hypertension
1
T.P (M)37
M.B
09/1951
F
Hyperlipidemia/ HTN
2
K.B (M)/38 & N. B(F)/35
Are any of the above half-brothers/sisters and/or stepbrothers/sisters? N/A
Other information of significance: Krabbe’s disease gene carrier
Maternal Grandfather
Name: C. P
Date and place of birth: 09/1938 Ethnic origin: White
How many brothers? 2 How many sisters? 2
Present health (if deceased, date and cause of death) N/A deceased at the age of from complications N/A
Maternal Grandmother
Name: D. P
Date and place of birth: 07/1942 Ethnic origin: White
How many brothers? 1 How many sisters? 1
Present health Hyperlipidemia & Cholesterol (if deceased, date and cause of death) deceased at the age of from complications N/A
Is there anyone else on the maternal side of the family that has any birth defects, mental retardation, or there any other health concerns not yet mentioned? List each person affected and identify the problems. Krabbe’s disease gene carrier from maternal side
Biological Father of Index Patient
Name: S. A Maiden (family) name: A
Date and place of birth: 08/1952, Kentucky Ethnic origin: White
Present health Krabbe’s disease gene carrier . Still alive (if deceased, date and cause of death) deceased at the age of 68 from complications
Father’s Brother and sisters and their Children
Include stillbirths(sb), miscarriages(m), deceased(d)
Name of Sibling
Date of birth month/year
Sex
Present Health
Sibling’s Children
List age & sex
J. A
08/1952
M
Good Health
1
T.A(M)
D. A
10/1950
M
Good Health
3
G.A(M), C.A(M) & L.A(F)
Are any of the above half-brothers/sisters and/or stepbrothers/sisters? N/A
Other information of significance: Family has Krabbe disease genetic disorder
Paternal Grandfather
Name: B. A
Date and place of birth: 05/15/XXXX Tennessee Ethnic origin: White
How many brothers? 2 How many sisters? 1
Present health Cardiovascular disease, Type 2 diabetes (if deceased, date and cause of death) deceased at the age of 78 from complications ____________________________
Paternal Grandmother
Name: L. A
Date and place of birth: 08/026/XXXX Tennessee Ethnic origin: White
How many brothers? 1 How many sisters? 1
Present health HTN, Hyperlipidemia, Rheumatoid Arthritis, Stroke (if deceased, date and cause of death) N/A deceased at the age of from complications
Is there anyone else on the paternal side of the family that has any birth defects, mental retardation, or there any other health concerns not yet mentioned? List each person affected and identify the problems. Krabbe’s disease gene carrier from paternal side

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