Appendix II Genetic Family history form Date: 01/23/2022 Date of Birth: 12/22/2010

Appendix II
Genetic Family history form
Date: 01/23/2022
Date of Birth: 12/22/2010 Sex: F Ethnicity: Black
Address: West Palm Beach, Florida
Phone number: XXXX Work number: XXXX
Occupation: Student Highest Grade Completed: Elementary
Name of spouse: XXXX
Date of Birth: XXXX
Referring doctor: Dr. N. C
Address: West Palm Beach, Florida
Family doctor: Dr. N. C
Address: West Palm Beach, Florida
Reason for Referral: Shortness and Wheezing
Medical Diagnosis (if known): Asthma
List any Health Problem you (the patient): Asthma
Name and Location
Reason
Date
N/A
N/A
N/A
N/A
N/A
N/A
List any Hospitalization (Place, Reason & date): Bustamante Children Hospital, Bacterial meningitis, 06/02/2013
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
A. D
05/2009
F
Good health
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Are any of the above half-brothers/sisters and/or stepbrothers/sisters? No
Are any of the above adopted or foster children? No
Biological Mother of Index Patient
Name: C. D Maiden (family) name: H
Date and place of birth: 08/04/88, Jamaica Ethnic origin: Jamaican-African
Present health Good Health (if deceased, date and cause of death) N/A 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
R. H
01/1979
M
Good Heath
J. W
12 M
T. H. R
01/1990
F
Asthma, SLE
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Are any of the above half-brothers/sisters and/or stepbrothers/sisters? No
Other information of significance: No
Maternal Grandfather
Name: C. H
Date and place of birth: 07/1961 Jamaica Ethnic origin: Jamaican-African
How many brothers? Unknown How many sisters? Unknown
Present health (if deceased, date and cause of death) Asthma deceased at the age of from complications N/A
Maternal Grandmother
Name: S. D
Date and place of birth: 03/1960 Jamaica Ethnic origin: Jamaican-African
How many brothers? 4 How many sisters? 4
Present health Good Health (if deceased, date and cause of death) N/A deceased at the age of N/A 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. No
Biological Father of Index Patient
Name: L. D Maiden (family) name: D
Date and place of birth: 06/18/1978 Jamaica Ethnic origin: Jamaican-African
Present health Good Health (if deceased, date and cause of death) N/A deceased at the age of N/A from complications N/A
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
L. D
03/1979
F
Good Health
2
12 F, 9 M
S. D
05/1982
M
Good Health
2
14 F, 7 M
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Are any of the above half-brothers/sisters and/or stepbrothers/sisters? No
Other information of significance: No
Paternal Grandfather
Name: E. D
Date and place of birth: 02/1957 Jamaica Ethnic origin: Jamaican-African
How many brothers? 2 How many sisters? 2
Present health Good Health (if deceased, date and cause of death) N/A deceased at the age of N/A from complications N/A
Paternal Grandmother
Name: D. D
Date and place of birth: 04/1961 Jamaica Ethnic origin: Jamaican-African
How many brothers? 3 How many sisters? 2
Present health Good Health (if deceased, date and cause of death) N/A deceased at the age of N/A from complications N/A
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. Unknown

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