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					    Family Medical History                                                            Current as of July 8, 2011
    For: Mary Smith McMahon


    Family Medical History for _____Mary Smith McMahon_____
    Go as far back as you or a relative can remember, great-aunts, great-great-uncles, 3rd cousins…

    To create a new row in any of the following tables, insert your cursor into the last cell of that table and
          press “Tab”

 Family Member                                             Age at                                  Other Health
                          Relationship
 (include names where                           Died                     Died From…
        known)
                              (to you)                     Death                                    Problems
Richard Anson Smith Father                    2/2/1972       45      Pneumonia                Hodgkin’s disease
                    Great-grandmother                                Cancer
                        Great-grandfather                            Alcoholism               Leg amputated for
                                                                                              circulatory problems
Gladys von Barth        Grandmother                          89      Uterine cancer?
Smith
John Smith              Grandfather                          56      Penumonia                Alcoholic
                                                                                              Leg amputated for
                                                                                              circulatory problems
                                                                                              sometime prior to 1953
John (Jack) Smith       Father’s   sibling                   55      Liver cancer             Alcoholic
June Smith              Father’s   sibling                   45      Bladder cancer           Depression
Shirley Smith           Father’s   sibling                                                    Thyroid problems
Francis (Frank)         Father’s   sibling                   44      AIDS
Smith

                                                                                                                        Last cell




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    Family Medical History                                                    Current as of July 8, 2011
    For: Mary Smith McMahon




 Family Member                                     Age at
                           Relationship
 (include names where                       Died                    Died From…       Other Health Problems
        known)
                              (to you)             Death
LaVon Dolores Bauer     Mother                                                       Quadruple bypass at age
Smith                                                                                67
                                                                                     High cholesterol
                        Great-grandmother
                        Great-grandfather
Bernice Thompson        Grandmother                 77      Stroke
Bauer
Walter Bauer            Grandfather                 75      Deteriorating organs     Bleeding ulcers
                                                                                     Obese
Walter Bauer            Mother’s sibling
Robert Bauer            Mother’s sibling                                             High cholesterol
Annabel Bauer           Mother’s sibling                                             Depression
                                                                                     Minor case of spina bifida
                                                                                     Back surgeries (fall from
                                                                                     horse, botched surgeries)


                                                                                                                Last cell




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    Family Medical History                                                   Current as of July 8, 2011
    For: Mary Smith McMahon


                        Your Siblings
 Family Member                                     Age at
                           Relationship
 (include names where                       Died                    Died From…      Other Health Problems
        known)
                                 (to you)          Death
Kathryn Dawn Smith      Sister                                                      Depression
Davie                                                                               High blood pressure
                                                                                    Obese
                                                                                    Acid reflux
                                                                                    Mild scoliosis?
                                                                                    Near-sighted
Patricia Ann Smith      Sister
Mary Louise Smith       Sister                                                      Varicose veins,
McMahon                                                                             Vascular circulatory
                                                                                    problems?
    Lauren McMahon      Daughter
Ann Marie Smith         Sister                                                      Scoliosis
Hessil                                                                              Varicose veins
Timothy Walter          Brother                                                     Quadruple bypass at age
Smith                                                                               39
Sara Lynn Smith         Sister                                                      Scoliosis             Last cell




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