[EDITORIAL NOTE]{.underline}: Because this questionnaire was intended to
provide names and addresses of relatives, many of whom would then be
contacted directly for physical examinations and more detailed
information, there was only minimal effort to identify the parents of
relatives who might be half-brothers and -sisters. If the information
provided will be the basis for constructing a family tree, the
questionnaire will have to be modified in a number of places:

(1) Several of the pages have, in the upper left-hand corner, "To whose
    children does this chart refer?" Add instructions that say, (All
    individuals in this page should share precisely the same birth
    parents; start a new page of the same color if the mother and/or the
    father changes.)

*This questionnaire is designed to be folded into booklet form. The page
numbers will make it clear how to fold the pages appropriately.*

OMB Number: 0925-0194

Expiration Date: June 30, 2000

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Family Number

family HISTORY questionnaire

> For each question, please check or record the appropriate response. If
> your answer does not fit one of the responses provided, feel free to
> write in your answer.
>
> STATEMENTS IN ALL CAPITAL LETTERS ARE INSTRUCTIONS TO YOU. SUCH
> STATEMENTS MAY INSTRUCT YOU TO SKIP CERTAIN QUESTIONS OR THEY MAY ASK
> YOU TO PROVIDE ADDITIONAL INFORMATION ON SOME FAMILY MEMBERS.
>
> When you are asked to provide information about children, we would
> like you to include all stillbirths and children who may not have
> lived past infancy.
>
> Please be as thorough as you can. If you don\'t know the answer to a
> question, please write DK in the space provided for the answer. There
> is space on page 16 for any additional information or other comments
> you may have.
>
> Public reporting burden for this collection of information is
> estimated to average 45 minutes per response, including the time for
> reviewing instructions, searching existing data sources, gathering and
> maintaining the data needed, and completing and reviewing the
> collection of information. An agency may not conduct or sponsor, and a
> person is not required to respond to, a collection of information
> unless it displays a currently valid OMB control number. Send comments
> regarding this burden estimate or any other aspect of this collection
> of information, including suggestions for reducing this burden, to:
> NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Room
> 1200, Bethesda, MD 20892-7974, ATTN: PRA (0925-0194). Do not return
> the completed form to this address.

1\. On what date was this questionnaire completed?

\|\_\_\_\_\_\_\|\_\_\_\_\_\_\|\_\_\_\_\_\_\|

Month Day Year

2\. Please record your full name, mailing address, and telephone
numbers.

Last Name First Name Middle Name (Maiden Name)

Number and Street Apt. \#

City State Zip

( ) ( )

Area Code Home Phone Area Code Office Phone

3\. When were you born?

\|\_\_\_\_\_\_\|\_\_\_\_\_\_\|\_\_\_\_\_\_\|

Month Day Year

4\. Where were you born?

City County State

OR

Foreign Country Year moved to U.S.A.

5\. Are you male or female?

Male

Female

18\. Who else might have more health information about your family?

NAME:

ADDRESS:

PHONE: [ (                      ) ]{.underline}

AREA CODE NUMBER

RELATIONSHIP TO YOU:

NAME:

ADDRESS:

PHONE: [ (                      ) ]{.underline}

AREA CODE NUMBER

RELATIONSHIP TO YOU:

> Please use this space to write in any additional information about
> your family\'s medical history or any other comments you may have.

PLEASE BRIEFLY REVIEW THE QUESTIONNAIRE TO MAKE SURE\
YOU HAVE NOT OMITTED ANY INFORMATION.

Thank you again for participating in our study of disease in families.
Please return all blank charts with your completed questionnaires and
charts.

6a. Do you consider yourself to be:

Hispanic or Latino

Not Hispanic or Latino

6b. What is your race?

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific\
   Islander

White

7\. What is your national origin or ancestry? (CHECK NO MORE THAN 4.)

+-----------------------------------+-----------------------------------+
| England                           | Middle East                       |
|                                   |                                   |
| Ireland                           | India, Pakistan                   |
|                                   |                                   |
| Germany                           | China                             |
|                                   |                                   |
| France                            | Japan                             |
|                                   |                                   |
| Italy                             | Other Asian countries or\         |
|                                   |    Pacific Islands                |
| Greece                            |                                   |
|                                   | Native American                   |
| Eastern Europe (e.g., Poland,\    |                                   |
|    Russia, Hungary,\              | Canada                            |
|    Czechoslovakia)                |                                   |
|                                   | Mexico                            |
| Scandinavia (e.g., Norway,\       |                                   |
|    Sweden, Denmark, Finland)      | Puerto Rico                       |
|                                   |                                   |
| Spain, Portugal                   | Central America                   |
|                                   |                                   |
| Other European Countries          | South America                     |
|                                   |                                   |
| Africa                            | Other (Specify)                   |
+-----------------------------------+-----------------------------------+

8\. Were you raised by someone other than your parents?

No

Yes:

Name Relationship

Name Relationship

9\. Are you a twin or one of a multiple birth?

No GO TO Q.10

Yes COMPLETE

Q.9a-c

9a. How many other infants were born with you?

\_\_\_\_\_\_\_\_

NUMBER

9b. Of those born with you, how many are of an identical relation with
you?

\_\_\_\_\_\_\_\_

NUMBER

9c. Of those born with you, how many are of a fraternal (non-identical)\
relation with you?

\_\_\_\_\_\_\_\_

NUMBER

10\. In what religion were you raised? Please note that this religion
may differ\
from the religion that you practice as an adult.

None

Catholic

Jewish

Greek Orthodox

Mormon

Seventh Day Adventist

Christian Scientist

Protestant

   If Protestant, what denomination?

   

Other

   If Other, please specify

   

**CHART**

+------------------+-------------------+-------------------+----------+
| Did this person  | ANSWER ONLY IF    |                   | How many |
| ever\            | PERSON IS DEAD    |                   | children |
| have cancer, a   |                   |                   | did this |
| tumor,\          |                   |                   | person   |
| or a growth?     |                   |                   | have?    |
+------------------+-------------------+-------------------+----------+
|                  | Date, place of    | Hospital where    |          |
|                  | death,\           | died              |          |
|                  | cause of death    |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+

**PLEASE COMPLETE THIS CHART FOR ANY RELATIVE WITH CANCER ADDITIONAL
RELATIVES'**\
FOR WHOM YOU HAVE NOT FILLED OUT INFORMATION IN EARLIER\
SECTIONS OF THIS QUESTIONNAIRE.

+-----------------+-----------------------------------------------------+
| Relationship\   | Name, date of birth and, if living,\                |
| to you          | address and phone number                            |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+

11\. What is the name, office address, and office phone number of your\
regular doctor?

Last Name First Middle

Street Address Apt. \#

City State Zip

( )

Area Code Office Phone

12\. Did a physician ever state that you had cancer?

No GO TO Q.13

Yes COMPLETE

Q.12a-d

12a. What type of cancer did the physician state you had? Where did it\
begin in your body?

Type Place it Began

12b. When did the physician diagnose this cancer?

Year

12c. What is the name and office address of the physician who diagnosed\
this cancer?

Last Name First Middle

Street Address Apt. \#

City State Zip

12d. What is the name and address of the hospital or health care
facility where the diagnosis was made?

Hospital/Clinic Name

Street Address

City State Zip

13\. What is your marital status?

Married or living as married

Widowed

Separated

Never married

Divorced

Remarried

IF YOU HAVE EVER BEEN MARRIED, ANSWER Q.14 THROUGH Q.17.\
IF YOU PARENTED CHILDREN WITH A PERSON TO WHOM YOU WERE\
NOT MARRIED, CONSIDER THAT PERSON AS A SPOUSE.

14\. What is the full name and birthdate of your current or most recent
spouse?

Last Name First Name Middle Name (Maiden Name)

Date of Birth \|\_\_\_\_\_\_\|\_\_\_\_\_\_\|\_\_\_\_\_\_\|

Month Day Year

**CHART**

+------------------+-------------------+-------------------+----------+
| Did this person  | ANSWER ONLY IF    |                   | How many |
| ever\            | PERSON IS DEAD    |                   | children |
| have cancer, a   |                   |                   | did this |
| tumor,\          |                   |                   | person   |
| or a growth?     |                   |                   | have?    |
+------------------+-------------------+-------------------+----------+
|                  | Date, place of    | Hospital where    |          |
|                  | death,\           | died              |          |
|                  | cause of death    |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| (Year)           |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| (Year)           |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| (Year)           |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| (Year)           |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+

**IF YOU HAVE ADDITIONAL RELATIVES WITH CANCER, GO TO NEXT PAGE.**

**PLEASE COMPLETE THIS CHART FOR ANY RELATIVE WITH CANCER ADDITIONAL
RELATIVES'**\
FOR WHOM YOU HAVE NOT FILLED OUT INFORMATION IN EARLIER\
SECTIONS OF THIS QUESTIONNAIRE.

+-----------------+-----------------------------------------------------+
| Relationship\   | Name, date of birth and, if living,\                |
| to you          | address and phone number                            |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+
| \_              | [(                        ) ]{.underline}           |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Last First Middle Maiden                            |
|                 |                                                     |
| Relationship    | Street Address                                      |
|                 |                                                     |
| \_              | City State Zip                                      |
| \_\_\_\_\_\_\_\ |                                                     |
| _\_\_\_\_\_\_\_ | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| Mother          | Area Code Number                                    |
|                 |                                                     |
| \_              | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\ | YR\_\_\_\_\_\_                                      |
| _\_\_\_\_\_\_\_ |                                                     |
|                 |                                                     |
| Father          |                                                     |
+-----------------+-----------------------------------------------------+

15\. With this spouse, did you parent any children, including
stillbirths and children who may not have lived past infancy?

Yes

No

IF THE ANSWER TO Q.15 IS \"YES,\" FILL OUT A GREEN CHART FOR CHILDREN.
INSTRUCTIONS FOR FILLING OUT THE CHARTS IN THIS QUESTIONNAIRE APPEAR ON
THE YELLOW CHART.

IF YOU HAVE BEEN MARRIED [MORE THAN ONCE]{.underline}, ANSWER Q.16 AND
Q.17.\
IF YOU PARENTED CHILDREN WITH A PERSON TO WHOM YOU WERE\
NOT MARRIED, CONSIDER THAT PERSON AS A SPOUSE.

IF YOU HAVE NEVER HAD A CHILD, TURN THE PAGE AND COMPLETE THE CHART ON
YOUR PARENTS.

16\. What is the full name and birthdate of your first spouse?

Last Name First Name Middle Name (Maiden Name)

Date of Birth \|\_\_\_\_\_\_\|\_\_\_\_\_\_\|\_\_\_\_\_\_\|

Month Day Year

17\. Did you parent any children with this spouse?

Yes

No

IF THE ANSWER TO Q.17 IS \"YES,\" FILL OUT A SEPARATE GREEN CHART FOR
CHILDREN BY THIS FIRST SPOUSE.

IF YOU HAVE BEEN MARRIED MORE THAN TWICE, PLEASE LIST THE NAMES\
OF YOUR ADDITIONAL SPOUSES AND FILL IN SEPARATE GREEN CHARTS\
FOR CHILDREN BY ANY ADDITIONAL SPOUSES.

WHEN YOU HAVE COMPLETED ALL CHARTS FOR YOUR CHILDREN, PLEASE\
TURN TO PAGES 6 AND 7 AND FILL IN THE CHART ON YOUR PARENTS.

PARENTS'

+-----------------+-----------------------------------------------------+
| Relationship\   | Name, date of birth and, if living,\                |
| to you          | address and phone number                            |
+-----------------+-----------------------------------------------------+
| Mother          | [(                        ) ]{.underline}           |
|                 |                                                     |
|                 | Last First Middle Maiden                            |
|                 |                                                     |
|                 | Street Address                                      |
|                 |                                                     |
|                 | City State Zip                                      |
|                 |                                                     |
|                 | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
|                 | Area Code Number                                    |
|                 |                                                     |
|                 | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
+-----------------+-----------------------------------------------------+
| Father          |                                                     |
|                 |                                                     |
|                 | Last First Middle                                   |
|                 |                                                     |
|                 | Street Address                                      |
|                 |                                                     |
|                 | City State Zip                                      |
|                 |                                                     |
|                 | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
|                 | Area Code Number                                    |
|                 |                                                     |
|                 | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
+-----------------+-----------------------------------------------------+

CHART

+------------------+-------------------+-------------------+----------+
| Did this person  | ANSWER ONLY IF    |                   | How many |
| ever\            | PERSON IS DEAD    |                   | children |
| have cancer, a   |                   |                   | did this |
| tumor,\          |                   |                   | person   |
| or a growth?     |                   |                   | have?    |
+------------------+-------------------+-------------------+----------+
|                  | Date, place of    | Hospital where    |          |
|                  | death,\           | died              |          |
|                  | cause of death    |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | ENTER    |
|                  | \_\_\_\_\|\_\_\_\ |                   | THE      |
| Type or site     | _\_\|\_\_\_\_\_\| | City              | NUMBER   |
| Year             |                   |                   | OF       |
|                  | Month Day Year    | County State      | CHILDREN |
| Hospital where   |                   |                   | YOUR     |
| diagnosed        | City              | Physician (if     | M        |
|                  |                   | known)            | OTHER\'S |
| City State       | County State      |                   | PARENTS  |
|                  |                   |                   | HAD,     |
|                  | Cause             |                   | TOGETHER |
|                  |                   |                   | AND WITH |
|                  |                   |                   | OTHER    |
|                  |                   |                   | P        |
|                  |                   |                   | ARTNERS, |
|                  |                   |                   | IN THE   |
|                  |                   |                   | SPACE    |
|                  |                   |                   | BELOW.   |
|                  |                   |                   |          |
|                  |                   |                   | \_\_\_\_ |
|                  |                   |                   | \_\_\_\_ |
|                  |                   |                   |          |
|                  |                   |                   | Number   |
|                  |                   |                   |          |
|                  |                   |                   | FILL OUT |
|                  |                   |                   | A        |
|                  |                   |                   | [P       |
|                  |                   |                   | INK]{.un |
|                  |                   |                   | derline} |
|                  |                   |                   | AUNTS &  |
|                  |                   |                   | UNCLES   |
|                  |                   |                   | CHART    |
|                  |                   |                   | FOR      |
|                  |                   |                   | THESE    |
|                  |                   |                   | C        |
|                  |                   |                   | HILDREN. |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  |          |
|                  | \_\_\_\_\|\_\_\_\ |                   |          |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   |          |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | ENTER    |
|                  | \_\_\_\_\|\_\_\_\ |                   | THE      |
| Type or site     | _\_\|\_\_\_\_\_\| | City              | NUMBER   |
| Year             |                   |                   | OF       |
|                  | Month Day Year    | County State      | CHILDREN |
| Hospital where   |                   |                   | YOUR     |
| diagnosed        | City              | Physician (if     | M        |
|                  |                   | known)            | OTHER\'S |
| City State       | County State      |                   | PARENTS  |
|                  |                   |                   | HAD,     |
|                  | Cause             |                   | TOGETHER |
|                  |                   |                   | AND WITH |
|                  |                   |                   | OTHER    |
|                  |                   |                   | P        |
|                  |                   |                   | ARTNERS, |
|                  |                   |                   | IN THE   |
|                  |                   |                   | SPACE    |
|                  |                   |                   | BELOW.   |
|                  |                   |                   |          |
|                  |                   |                   | \_\_\_\_ |
|                  |                   |                   | \_\_\_\_ |
|                  |                   |                   |          |
|                  |                   |                   | Number   |
|                  |                   |                   |          |
|                  |                   |                   | FILL OUT |
|                  |                   |                   | A        |
|                  |                   |                   | [P       |
|                  |                   |                   | INK]{.un |
|                  |                   |                   | derline} |
|                  |                   |                   | AUNTS &  |
|                  |                   |                   | UNCLES   |
|                  |                   |                   | CHART    |
|                  |                   |                   | FOR      |
|                  |                   |                   | THESE    |
|                  |                   |                   | C        |
|                  |                   |                   | HILDREN. |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  |          |
|                  | \_\_\_\_\|\_\_\_\ |                   |          |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   |          |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   |          |
| diagnosed        | City              | Physician (if     |          |
|                  |                   | known)            |          |
| City State       | County State      |                   |          |
|                  |                   |                   |          |
|                  | Cause             |                   |          |
+------------------+-------------------+-------------------+----------+

**GRANDPARENTS'**

+-----------------+-----------------------------------------------------+
| Relationship\   | Name, date of birth and, if living,\                |
| to you          | address and phone number                            |
+-----------------+-----------------------------------------------------+
| Mother\'s       | [(                        ) ]{.underline}           |
|                 |                                                     |
| Mother          | Last First Middle Maiden                            |
|                 |                                                     |
|                 | Street Address                                      |
|                 |                                                     |
|                 | City State Zip                                      |
|                 |                                                     |
|                 | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
|                 | Area Code Number                                    |
|                 |                                                     |
|                 | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
+-----------------+-----------------------------------------------------+
| Mother\'s       | Last First Middle                                   |
|                 |                                                     |
| Father          | Street Address                                      |
|                 |                                                     |
|                 | City State Zip                                      |
|                 |                                                     |
|                 | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
|                 | Area Code Number                                    |
|                 |                                                     |
|                 | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
+-----------------+-----------------------------------------------------+
| Father\'s       | [(                        ) ]{.underline}           |
|                 |                                                     |
| Mother          | Last First Middle Maiden                            |
|                 |                                                     |
|                 | Street Address                                      |
|                 |                                                     |
|                 | City State Zip                                      |
|                 |                                                     |
|                 | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
|                 | Area Code Number                                    |
|                 |                                                     |
|                 | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
+-----------------+-----------------------------------------------------+
| Father\'s       | Last First Middle                                   |
|                 |                                                     |
| Father          | Street Address                                      |
|                 |                                                     |
|                 | City State Zip                                      |
|                 |                                                     |
|                 | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
|                 | Area Code Number                                    |
|                 |                                                     |
|                 | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
+-----------------+-----------------------------------------------------+

CHART

+------------------+-------------------+-------------------+----------+
| Did this person  | ANSWER ONLY IF    |                   | How many |
| ever\            | PERSON IS DEAD    |                   | children |
| have cancer, a   |                   |                   | did this |
| tumor,\          |                   |                   | couple   |
| or a growth?     |                   |                   | have?    |
+------------------+-------------------+-------------------+----------+
|                  | Date, place of    | Hospital where    |          |
|                  | death,\           | died              |          |
|                  | cause of death    |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | ENTER    |
|                  | \_\_\_\_\|\_\_\_\ |                   | THE      |
| Type or site     | _\_\|\_\_\_\_\_\| | City              | NUMBER   |
| Year             |                   |                   | OF       |
|                  | Month Day Year    | County State      | CHILDREN |
| Hospital where   |                   |                   | YOUR     |
| diagnosed        | City              | Physician (if     | PARENTS  |
|                  |                   | known)            | HAD,     |
| City State       | County State      |                   | TOGETHER |
|                  |                   |                   | AND WITH |
|                  | Cause             |                   | OTHER    |
|                  |                   |                   | P        |
|                  |                   |                   | ARTNERS, |
|                  |                   |                   | IN THE   |
|                  |                   |                   | SPACE    |
|                  |                   |                   | BELOW.   |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   | FILL OUT |
| diagnosed        | City              | Physician (if     | SISTERS  |
|                  |                   | known)            | &        |
| City State       | County State      |                   | BROTHERS |
|                  |                   |                   | CHART ON |
|                  | Cause             |                   | THE NEXT |
|                  |                   |                   | PAGE.    |
+------------------+-------------------+-------------------+----------+

**To whose children does this chart refer? SISTERS' AND BROTHERS'**

**\| **

**Mother\'s Name Father\'s Name**

LIST IN ORDER OF BIRTH

+-----------------+-----------------------------------------------------+
| Relationship\   | Name, date of birth and, if living,\                |
| to you          | address and phone number                            |
+-----------------+-----------------------------------------------------+
| Sister          | [(                        ) ]{.underline}           |
|                 |                                                     |
| Brother         | Last First Middle Maiden                            |
|                 |                                                     |
| Half-Brother    | Street Address                                      |
|                 |                                                     |
| (same mother)   | City State Zip                                      |
|                 |                                                     |
| Half-Brother    | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| (same father)   | Area Code Number                                    |
|                 |                                                     |
| Half-Sister     | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
| (same mother)   |                                                     |
|                 |                                                     |
| Half-Sister     |                                                     |
|                 |                                                     |
| (same father)   |                                                     |
+-----------------+-----------------------------------------------------+
| Sister          | [(                        ) ]{.underline}           |
|                 |                                                     |
| Brother         | Last First Middle Maiden                            |
|                 |                                                     |
| Half-Brother    | Street Address                                      |
|                 |                                                     |
| (same mother)   | City State Zip                                      |
|                 |                                                     |
| Half-Brother    | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| (same father)   | Area Code Number                                    |
|                 |                                                     |
| Half-Sister     | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
| (same mother)   |                                                     |
|                 |                                                     |
| Half-Sister     |                                                     |
|                 |                                                     |
| (same father)   |                                                     |
+-----------------+-----------------------------------------------------+
| Sister          | [(                        ) ]{.underline}           |
|                 |                                                     |
| Brother         | Last First Middle Maiden                            |
|                 |                                                     |
| Half-Brother    | Street Address                                      |
|                 |                                                     |
| (same mother)   | City State Zip                                      |
|                 |                                                     |
| Half-Brother    | Phone: [ (                   ) ]{.underline}        |
|                 |                                                     |
| (same father)   | Area Code Number                                    |
|                 |                                                     |
| Half-Sister     | Date of Birth: MO\_\_\_\_\_\_ DAY\_\_\_\_\_\_       |
|                 | YR\_\_\_\_\_\_                                      |
| (same mother)   |                                                     |
|                 |                                                     |
| Half-Sister     |                                                     |
|                 |                                                     |
| (same father)   |                                                     |
+-----------------+-----------------------------------------------------+

**CHART**

+------------------+-------------------+-------------------+----------+
| Did this person  | ANSWER ONLY IF    |                   | How many |
| ever\            | PERSON IS DEAD    |                   | children |
| have cancer, a   |                   |                   | did this |
| tumor,\          |                   |                   | person   |
| or a growth?     |                   |                   | have?    |
+------------------+-------------------+-------------------+----------+
|                  | Date, place of    | Hospital where    |          |
|                  | death,\           | died              |          |
|                  | cause of death    |                   |          |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   | FILL     |
| diagnosed        | City              | Physician (if     | OUT\     |
|                  |                   | known)            | A        |
| City State       | County State      |                   | [WH      |
|                  |                   |                   | ITE]{.un |
|                  | Cause             |                   | derline} |
|                  |                   |                   | CHART    |
|                  |                   |                   | FOR      |
|                  |                   |                   | NIECES   |
|                  |                   |                   | AND      |
|                  |                   |                   | NEPHEWS. |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   | FILL     |
| diagnosed        | City              | Physician (if     | OUT\     |
|                  |                   | known)            | A        |
| City State       | County State      |                   | [WH      |
|                  |                   |                   | ITE]{.un |
|                  | Cause             |                   | derline} |
|                  |                   |                   | CHART    |
|                  |                   |                   | FOR      |
|                  |                   |                   | NIECES   |
|                  |                   |                   | AND      |
|                  |                   |                   | NEPHEWS. |
+------------------+-------------------+-------------------+----------+
| Yes No DK        | \|\_              | Name of Hospital  | \_\_\_\_ |
|                  | \_\_\_\_\|\_\_\_\ |                   | \_\_\_\_ |
| Type or site     | _\_\|\_\_\_\_\_\| | City              |          |
| Year             |                   |                   | Number   |
|                  | Month Day Year    | County State      |          |
| Hospital where   |                   |                   | FILL     |
| diagnosed        | City              | Physician (if     | OUT\     |
|                  |                   | known)            | A        |
| City State       | County State      |                   | [WH      |
|                  |                   |                   | ITE]{.un |
|                  | Cause             |                   | derline} |
|                  |                   |                   | CHART    |
|                  |                   |                   | FOR      |
|                  |                   |                   | NIECES   |
|                  |                   |                   | AND      |
|                  |                   |                   | NEPHEWS. |
+------------------+-------------------+-------------------+----------+

**IF YOU HAVE ADDITIONAL SISTERS AND BROTHERS, FILL OUT THE
[WHITE]{.underline} SISTERS AND BROTHERS CHART.**