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 MALE QUESTIONNAIRE - PAGE 8(a) 

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There are sometimes risk factors associated with conditions that your close relatives (grandparents, parents, brothers or sisters) have had... if you know of any, please tell us here.
904.  Allergies in close family members?
None / don't know
Minor in one parent
Minor in two parents or significant in one
Significant in two parents
Severe in two parents
905.  Alzheimer's Disease in close family members?
None / don't know
Probably in one family member
Probably in more than one family member
Yes, in one family member
Yes, in more than one family member
906.  Cancer (of ANY type, including those mentioned below) in close family members?
None / don't know
Probably, one family member
Probably, more than one family member
Yes, one family member
Yes, more than one family member
907.  Melanoma (a dangerous form of skin cancer) in close family members?
None / don't know
Probably, in one parent or sibling
Probably, in two or more parents or siblings
Yes, in one parent or sibling
Yes, in more than one parent or sibling
908.  Cancer of the colon / rectum in close family members?
None / don't know
Probably, in parent(s) or sibling(s)
Yes, in one parent or sibling
Yes, in more than one parent or sibling
909.  Chronic Fatigue in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
910.  Colitis (inflammation of the colon) or ulcerative colitis in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
911.  Depression in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
912.  Diabetes in either distant or close relatives?
None / don't know
Yes, in a distant relative
Yes, in 1 direct or 2 distant relatives
Yes, in 2 direct relatives
Yes, in more than 2 direct relatives
913.  If your father ever suffered heart attack(s), at approximately what age did they start?
Never / don't know
Over 60
51-60
41-50
40 or younger
914.  If your mother ever suffered heart attack(s), at approximately what age did they start?
Never / don't know
Over 80
71-80
61-70
60 or younger
915.  Aside from heart attacks, has there been any heart disease in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
916.  Did either of your parents suffer from hypertension?
None / don't know
Mild in one parent
Both parents mild or one parent moderate
Both parents moderate or one parent high
Both parents high or one parent severe
917.  Hyperthyroidism in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
918.  Hypothyroidism in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
919.  Kidney Stones in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
920.  Glaucoma in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
921.  Macular Degeneration in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
922.  Muscle pains in close family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one family member
Yes, in more than one family member
923.  Schizophrenia in close family members?
None / don't know
Yes, in one distant relative
Yes, in one direct relative or 2 distant relatives
Yes, in 2 direct relatives
Yes, in more than 2 direct relatives
924.  Stroke in close family members?
None / don't know
Yes, in one distant relative
Yes, in more than one distant relative
Yes, in one direct relative
Yes, in more than one direct relative
925.  Tuberculosis in family members?
None / don't know
Probably, in one family member
Probably, in more than one family member
Yes, in one or more family members
Yes, in more than one generation of family members

Add any additional information here for the questions above:

Please mention the question number(s) if possible.

 


 


GLOSSARY

Allergy (Allergies)
Hypersensitivity caused by exposure to a particular antigen (allergen), resulting in an increased reactivity to that antigen on subsequent exposure, sometimes with harmful immunologic consequences.

Alzheimer's Disease (Alzheimer's)
A progressive disease of the middle-aged and elderly, characterized by loss of function and death of nerve cells in several areas of the brain, leading to loss of mental functions such as memory and learning. Alzheimer's disease is the most common cause of dementia.

Cancer
Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.

Chronic Fatigue Syndrome (CFS, Chronic Fatigue)
A disorder of unknown cause that lasts for prolonged periods and causes extreme and debilitating exhaustion as well as a wide range of other symptoms such as fever, headache, muscle ache and joint pain, often resembling flu and other viral infections. Also known as Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS), Chronic Epstein-Barr Virus (CEBV), Myalgic Encephalomyelitis (ME), "Yuppy Flu" and other names, it is frequently misdiagnosed as hypochondria, psychosomatic illness, or depression, because routine medical tests do not detect any problems.

Colitis
Colon inflammation, usually involving the mucus membranes. Mucus colitis is a type with cramps, periods of constipation, and copious discharge of mucus with feces. Ulcerative colitis has pain, inflammation, ulceration, fever, and bleeding, all interspersed at various times - a long and serious illness.

Colon (Colonic)
The part of the large intestine that extends to the rectum. The colon takes the contents of the small intestine, moving them to the rectum by contracting.

Diabetes Mellitus (Diabetes, Diabetic, Diabetics)
A disease with increased blood glucose levels due to lack or ineffectiveness of insulin. Diabetes is found in two forms; insulin-dependent diabetes (juvenile-onset) and non-insulin-dependent (adult-onset). Symptoms include increased thirst; increased urination; weight loss in spite of increased appetite; fatigue; nausea; vomiting; frequent infections including bladder, vaginal, and skin; blurred vision; impotence in men; bad breath; cessation of menses; diminished skin fullness. Other symptoms include bleeding gums; ear noise/buzzing; diarrhea; depression; confusion.

Glaucoma
A disease of the eye characterized by vision loss due to an increase in the pressure of fluid within the eye. This rise in pressure results from a build-up of aqueous fluid and leads to progressive damage to the optic nerve that transmits visual signals to the brain. Over time, glaucoma can lead to a gradual loss in peripheral vision. There are usually no signs that you're developing glaucoma until vision loss occurs.

Hypertension
High blood pressure. Hypertension increases the risk of heart attack, stroke, and kidney failure because it adds to the workload of the heart, causing it to enlarge and, over time, to weaken; in addition, it may damage the walls of the arteries.

Hyperthyroidism (Hyperthyroid)
An abnormal condition of the thyroid gland resulting in excessive secretion of thyroid hormones characterized by an increased metabolism and weight loss.

Hypothyroidism (Hypothyroid)
Diminished production of thyroid hormone, leading to low metabolic rate, tendency to gain weight, and sleepiness.

Kidney Stone (Kidney Gravel, Kidney Stones)
A stone (concretion) in the kidney. If the stone is large enough to block the tube (ureter) and stop the flow of urine from the kidney, it must be removed by surgery or other methods. Also called Renal Calculus. Symptoms usually begin with intense waves of pain as a stone moves in the urinary tract. Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin. The pain may continue if the stone is too large to pass; blood may appear in the urine and there may be the need to urinate more often or a burning sensation during urination. If fever and chills accompany any of these symptoms, an infection may be present and a doctor should be seen immediately.

Macular Degeneration
Increasingly poor eyesight often accompanied by light sensitivity, distorted vision and a blank or dark patch in the center of vision.

Melanoma
A life-threatening type of skin cancer that occurs in the cells (melanocytes) that produce melanin, the pigment found in skin, hair, and the iris of the eyes.

Schizophrenia
Any of a group of psychotic disorders usually characterized by withdrawal from reality, illogical patterns of thinking, delusions, and hallucinations, and accompanied in varying degrees by other emotional, behavioral, or intellectual disturbances. Schizophrenia is associated with dopamine imbalances in the brain and defects of the frontal lobe and is caused by genetic, other biological, and psychosocial factors.

Stroke (Stroke-Type Event)
A sudden loss of brain function caused by a blockage or rupture of a blood vessel that supplies the brain, characterized by loss of muscular control, complete or partial loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severity of the damage to the brain. The most common manifestation is some degree of paralysis, but small strokes may occur without symptoms. Usually caused by arteriosclerosis, it often results in brain damage.

Tuberculosis
Also known as TB, Consumption or "The White Plague", tuberculosis is an infectious disease caused by a bacterium called Mycobacterium tuberculosis, usually affecting the lungs but possibly also the brain, kidneys and bones. Patients may at first be symptom-free or experience a flu-like illness. In the secondary stage, there might be a slight fever, night sweats, weight loss, fatigue and various other symptoms, depending on the part of the body affected. Tuberculosis of the lung is usually associated with a dry cough that eventually leads to a productive cough with blood-stained sputum. There might also be chest pain and shortness of breath.

Ulcerative Colitis (Colitis Ulcerosa)
Ulceration of the colon and rectum, usually long-term and characterized by rectal bleeding or blood in the stool, frequent urgent diarrhea/bowel movements each day, abdominal pain.





























 

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