Medical Family Tree

Prepared by Sheila Axtman Kokkeler for the Axtman Family Reunion, Rugby, ND, July, 1999

Of the 10,000 diseases known to medicine, at least 3,000 are genetic imprints (inherited). It is for this reason, doctors are always asking what diseases or conditions run in the family. When one has an extended and large family, it is difficult to know the answers. That is why we are putting together a family medical tree and asking you to share any pertinent information with us by filling out this form. It is strictly voluntary. We will compile all the information received and share it with any family member who requests it.

Feel free to include and elaborate on any other condition which may not be listed on this form. We did not have anything to use as a guide. It is important to remember that we share 50% of the genes of our parents and siblings and 25% of the genes our aunts, uncles, and grandparents.

Name:_______________________ Send me a copy of compiled history:__________

List any members of your family (parents, brothers/sisters, children) who are deceased and what the cause of death was.





Members of your immediate family and their afflictions/disease/surgeries. If there's diabetes or arthritis be sure to specify if it was early or late onset. (Use back if needed.)

Stroke
Cancer
Asthma
Epilepsy
Ulcers
Tumors
Migraine
Leukemia
High Blood Pressure
Parkinson's Disease
Muscular Dystrophy
Lou Gehrig's Disease
Huntington's Disease
Congenital Problems
Emphysema
Bleeding Tendencies
High Cholesterol
Rheumatic Heart
Multiple Sclerosis
Eczema/psoriasis
Mental Illness
Alzheimer's
Hay Fever
Surgeries
Thyroid Disease
Kidney Disease
Tuberculosis
Cystic Fibrosis
Heart Attack
Alcoholism
Glaucoma
Allergies
Diabetes
Arthritis
Colitis
Goiter
Lupus
Hives