Please complete and send a form with each family members sample sent to Yale

Medical history and information sheet

We do not accept samples known to be HIV and or Hepatitis POSITIVE

Todays date _________________________
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Name ____________________________________________
Address ____________________________________________________________________________________
city
state
zip
phone/ email _____________________________________________________
Date of birth _______________
Gender _______
Height _______ Weight _________
Race __________________ [i.e. Caucasian, Hispanic, African, Asian, South Asian, Native American etc.]
Ethnicity _______________ {ie Irish, Italian, Puerto Rican, Scottish, Russian, Scandinavian, Cuban, Jamaican etc.}
MOTHERS name [including maiden name] ___________________________________
mothers MOTHERS name [including maiden name] ___________________________________
mothers FATHERS name] _________________________________________
FATHERS name ______________________________________________________
fathers MOTHERS name [including maiden name ] ___________________________________
fathers FATHERS name] _________________________________________
Are parents and /or grandparents related? NO _________
YES describe _______________________________________________________________________
Medical history
Dermatological condition __________________________________ age at diagnosis __________
Genetic testing done? reason ______________________________ when _____________________________
where ___________________________________
results ________________________________________
Other medical conditions
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Medications [including over the counter]
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please list family members [and relationship] with dermatological conditions

Additional family medical history

_____________________________________________________________________________________________
_____________________________________________________________________________________________

Names of other family members participating in this study ______________________________________ _________

_____________________________________________________________________________________________
Dermatologists name:
Keith Choate MD PhD

phone/email
Fax 888 480-7802

phone 203 7853912