Health, Social, Educational, and Genetic History (HSEGH)

General Information

First Name: *

Last Initial Only: *

Age: *

Place of Birth: * 🛈

Religion (if any):

Ethnic Heritage (Irish, German, Chilean, Mexican, etc.):

Height: *

Weight: *

Eye Color: *

Natural Hair Color: *

Skin Color: *

Please list any unique physical characteristics you might have (freckles, long eyelashes, etc.):

Describe your personality (outgoing, shy, humorous, sarcastic, energetic, laid back, etc.):

Describe your interests, special talents or hobbies (music, art, sports, etc.):

Please describe your work history:

Are you adopted?

Yes

If yes, at what age If yes, at what age

Please describe any criminal history:

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Genetic History

Do you or your relatives have the following mental or physical health issues? *

	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Anxiety Disorder Diagnosis	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Attention Deficit Disorder (ADD)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Attention Deficit Hyperactivity Disorder (ADHD) Diagnosis	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Autism Spectrum Disorder	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Bi-Polar Disorder	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Borderline Personality Disorder	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Depression	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Dyslexia	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Schizoaffective Disorder	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Schizophrenia	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Other Mental Health Diagnoses: Please Explain	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
AIDS	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Acne	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Allergies (Food)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Allergies (Medicine)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Allergies (Seasonal)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Allergies (Other)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Alzheimer’s Disease	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Arthritis	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Asthma	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Auto-Immune Disorder	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Birth Defects	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Birthmarks	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Cancer	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Cerebral Palsy	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Cleft Lip or Palate	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Club Foot	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Cystic Fibrosis	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Deformities	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Dental Problems	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Diabetes	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Downs Syndrome	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Dwarfism	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Eczema	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Epilepsy	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Wear Glasses or Contacts (Nearsighted or Farsighted)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Major Eyesight Problems or Blindness	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
HIV Positive	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Hearing Problems or Deafness	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Heart Attack	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Heart Disease	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Heart Murmur	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Hemophilia	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Hepatitis B	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Hepatitis C	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Herpes Virus	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
High Blood Pressure	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
High Cholesterol	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Infertility	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Kidney Problems	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Learning Disability	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Left Handed	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Mental Retardation	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Miscarriage	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Multiple Sclerosis	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Obesity	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Scoliosis	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Seizures	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Sickle Cell	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Spina Bifida	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Stillbirth	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Stroke	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Stuttering	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Sudden Infant Death Syndrome (SIDS)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Thyroid Problems	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Tourette Syndrome	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Other:	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Alcohol Addiction	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Cocaine Addiction	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Heroin Addiction	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Marijuana Use	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Methamphetamine Addiction	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Prescription Opioids Addiction (morphine, oxycodone, OxyContin, Percocet, Vicodin, Methadone)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Prescription Sedatives Addiction (Lorazepam (Ativan), Diazepam (Valium), Clonazepam (Klonopin), Alprazolam (Xanax)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Prescription Stimulants Addiction (Adderall, Ritalin, Concerta, Daytrana)	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?
Other Substance Use during this Pregnancy:	Yes - Myself	No - Myself	Yes - My Family	No - My Family	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?	Please specify any details in the box below. (Example: date of diagnosis, medications/treatment, etc)?

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