Survey on psychiatric covariation

Fill in below as well as you can

Psychiatric diagnosis or self-diagnosis


Age


Gender


Age at death of:

Mothers mother:      Fathers mother:     Mothers father:      Fathers father:


Hemochromatosis

Own          Parent          Sibling          Relative


Cystic Fibrosis

Own          Parent          Sibling          Relative


Factor V Leiden

Own          Parent          Sibling          Relative


Huntington's Disease

Own          Parent          Sibling          Relative


Parkinson

Own          Parent          Sibling          Relative


Psoriasis

Own          Parent          Sibling          Relative


Fibromyalgia

Own          Parent          Sibling          Relative


Multiple Sclerosis

Own          Parent          Sibling          Relative


Crooked tooth or underbite

Own          Parent          Sibling          Relative


Flat-footed

Own          Parent          Sibling          Relative


Natural red or auburn hair color

Own          Parent          Sibling          Relative


Freckles

Own          Parent          Sibling          Relative


Rhesus (RH) negative

Own          Parent          Sibling          Relative


Comments