| Age(s) now/at death | Medical problem(s) |
Mother ☐ Y ☐ N |
|
|
Father ☐ Y ☐ N |
|
|
Sister(s) ☐ Y ☐ N |
|
|
Brother(s) ☐ Y ☐ N |
|
|
Daughter(s) ☐ Y ☐ N |
|
|
Son(s) ☐ Y ☐ N |
|
|