Document aJxdR5Zaa1OE51kyqOL2ObVmN

Study ID Number _ _ _ __ Name _ _ __ Part2 Family History FHl Is your father living? Do not know D Yes D FH12 Age _ _ _ _ _ __ No D FH13 Yearofdeath _ _ __ FH14 Age at death _ _ _ __ FH15 Cause of death _ _ _ _ __ FH2 Is your mother living? Yes D Do not know D FH22 No D FH23 Yearofdeath _ _ __ FH24 Age at death _ _ _ __ FH25 Cause of death _ _ _ _ __ Age _____________ FH3 How many children did your parents have? _ __ FH4 Are your siblings living? Sex (M/F) Living 1. Sibling # 2. Sibling # 3. Sibling # 4. Sibling #_ 5. Sibling #_ 6. Sibling #_ 7. Sibling #_ 8. Sibling #_ 9. Sibling # 10. Sibling # Age: Age: Age: Age: Age: Age: Age: Age: Age: Age: Dead - Date of Age at death: death Cause of death: FH5 Has an immediate relative (Father, Mother, Sibling) been diagnosed with any of the following diseases? (See list) [J No D Do not know [J Yes, If yes, which relation: [J Relationship Disease Age at diagnosis _ _ [J Relationship Disease Age at diagnosis _ _ [J Relationship Disease Age at diagnosis _ _ 1. Leukemia 11. Acute Myeloid Leukemia, 13Acute Lymphocytic Leukemia, 15 Other/not known 2. Non-Hodgkin's lymphoma 12. Chronic Myeloid Leukemia 14. Chronic Lymphocytic Leukemia, Version 24 February 2004 CC_DP Questionnaire 3 of 15 SH ELL-MCCLU RG-059281