Family Health History Survey

What is your age?

What is your gender?

Male

Female

Other

Prefer not to say

Do you have any family history of the following medical conditions? (Check all that apply)

Diabetes

Hypertension

Heart Disease

Cancer

Stroke

Asthma

Arthritis

Alzheimer's Disease

Other (please specify)

If yes, please specify which family members have had these conditions:

Any additional information about your family's health history?

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