The Official Family Tree of Clyde Budd & Violet Marshall Budd
 

 

 
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Survey: Family Health History
Please fill out the following information to the best of your knowledge. This information is gathered to determine if a certain type of illness or cancer runs in the family and will be posted on a general family Health Chart. Please fill out a separate survey for each individual person.
Submitted by:  
Email Address
Relationship to You              Self  Mother  Father  Brother  Sister  Half Brother/Sister Child
  Grand Mother   Grand Father   Uncle   Aunt  Niece  Nephew
   
►Name
►Date of Birth   / /
►Place of Birth:   City State 
►Other Names known by
    (Marriages or otherwise)
►I was Born: A Single Birth  As Twins   Multiple Birth: How Many
  Naturally   by C-Section 
  With a  Birth Defect               What Type    

Any Complications?
►I have had: (For Females Only)   # Children by  Single Birth  Twins   Multiple Birth:
  Natural     by C-Section    Hysterectomy
  A Child Born With Birth Defect          What Type  

Any Complications?
►Childhood Illness/Conditions Diabetes 1   Measles   Chicken Pox   Mumps    Rubella
  Appendicitis      Tonsilectomy  Adnoids Removed    Sleep Apnea
  Asthma  Pneumonia    Anemia   Heart Murmur Spleen Damage
  Bi-Polar  ADD (Attention Deficient) ADHD (Attention HYPER Deficient)
  Over-Active Thyroid (Graves Disease)  Under-Active Thyroid  Obesity
  Muscular Dystrophy   Cystic Fibrosis  
  Scarlet Fever   Rheumatic Fever    Polio   Whooping Cough
  Tuberculosis  Lyme Disease Epilepsy    Migraine
  Broken Bones:        What Type    
  Blindness  at Birth   Right Eye  Left Eye  Both Eyes
  Blindness  by Accident   Right Eye  Left Eye  Both Eyes 
  Blindness  by Illness (such as Diabetes) Right Eye  Left Eye  Both Eyes
  Down Syndrome  Other Retardation /What Type    
►Childhood Allergies Penicillin   Latex   Cats   Dogs  

Other: 
►Childhood Accidents Concussion   Whiplash
►Childhood Scars
►Operations  Appendicitis     Tonsilectomy    Adnoids Removed  
  Other:
  Organ Transplant        What Type    
  Radiation Treatments       Chemotherapy   For:
►Other Illness / Condition
   (Not Listed Above) 
►Adult Health Issues Diabetes 1  Diabetes 2     Any Amputations
  Emphysema  Asthma  Lung/Respiratory   Pneumonia  Tuberculosis 
  Sleep Apnea    Fibromyalsia  
  Arthritis   Osteoporosis    Gout   Carpal Tunnel   Tennis Elbow
  Broken Bones:        What Type    
  Cardiovascular Disease  Heart Murmur   Heart Attacks  
  Alzheimers    Stroke     High Blood Pressure    Anemia 
  Other Dementia    /   Caused by  Natural / Old Age   Stroke    Accident
  Epilepsy   Migraine   Ulcers Lupus    Hepatitis B    Hepatitis C 
  Alcoholism  Liver Disease  Kidney Disease  Gall Bladder/Stones
  Drug Dependency  Herpes  HIV
  Blindness  by Accident   Right Eye  Left Eye  Both Eyes 
  Blindness  by Illness (such as Diabetes) Right Eye  Left Eye  Both Eyes
►Operations Appendicitis     Tonsilectomy    Adnoids Removed  
  Hip Replacement  Knee /Replacement   Bi-Pass Operations
  Organ Transplant        What Type    
  Radiation Treatments       Chemotherapy   For:
  Other:    
►Adult Allergies Penicillin   Latex   Cats   Dogs  
Other: 
►Adult Accidents Concussion   Whiplash
►Adult Scars
►Smoker Yes   How Many Years?            Yes But Quit      No/ Never 
►Cancers Breast  Prostate  Brain   Liver   Kidney  Stomach  Colon
  Other Type of Cancer  
► Other Illness / Condition
     (Not Listed Above)

► Sexual Orientation
(Health History Chart info Only)

 Straight   Gay Male   Lesbian   Bi-Sexual    Hermaphrodite
   
►Date of Death (if applicable)   / /
►Place of Death  City State 
►Cause of Death Stroke  Hearth Attack   Heart Disease  Alzheimer's
  Natural Causes / Old Age   Crib Death
  Complications from      Other  
  Cancer    What Type of Cancer   (Breast, Skin, Prostate, Brain)
  Car Accident  Homicide  Suicide  Accidental Overdose  Drugs
  Details 
►Age at Death
   
►Place of Burial: Cemetery Name Plot #
►Place of Burial: City / State City  State 
►Cremation? Yes 
►Ashes spread? YES  NO    If Yes, Location: (At Sea, Mts, etc)
   

Thank You for Your Help!