Please provide information about yourself and your family's background Part-1 Part-2 Part-3 Part-4 Part-5 Personal Information First Name Last Name Email Repeat to confirm Date of Birth Gender Male Female Prefer not to say Country of Birth select country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic of the Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Which Part of the Country North North-East North-West East West South South-East South-West Ancestry Information Ethnicity English Welsh Scottish Northern Irish Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African Any other Mixed or Multiple background Indian Pakistani Bangladeshi Chinese Any other Asian background African African American Caribbean Any other Black background Arab Hispanic Latino Native American Pacific Islander Any other ethnic group Other, Please specify Are there any specific genetic traits or conditions that are more common in your ethnic group? Yes No N/A Have any members of your family been diagnosed with a genetic condition that is more common in your ethnic group? Yes No N/A Medical History Are there any genetic conditions or traits that run in your family? Yes No N/A Have any of your family members been diagnosed with a genetic condition or had genetic testing done? Yes No N/A Have you taken any of the following Opioids Hormone Replacement Therapy (HRT) Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Immunomodulatory Drugs Metformin Corticosteroids Disease-Modifying Antirheumatic Drugs (DMARDs) Cyclosporine Azathioprine Mycophenolate Mofetil None of the Above Genetic issues in the family Which family members have been diagnosed with a genetic condition? Have any of your family members had genetic testing done? If so, what were the results? Please upload the results. if available Choose a file Max. size: 100.0 MB Other Health Issues Have any of your family members been diagnosed with type 2 diabetes or heart disease? Yes No N/A Are there any other health conditions that run in your family that may have a genetic component? Yes No N/A Any Comments? SHOW SUMMARY Some required Fields are emptyPlease check the highlighted fields. 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