Genomics Research Centre // General Public

Genomics Research Centre Online Questionnaire
Diseases Page (Page 1 of 8)

Have you ever been diagnosed with any of the following diseases? Please indicate:

Asthma

Yes
No

Glaucoma

Yes
No

A.D.D

Yes
No

Gastric Ulcers

Yes
No

Autism

Yes
No

Heart Disease

Yes
No

Alcoholism

Yes
No

Irritable Bowel Syndrome

Yes
No

Breast Cancer

Yes
No

Lactose Intolerance

Yes
No

Cancer (any other form)

Yes
No

Migraine

Yes
No

Chronic Fatigue Syndrome

Yes
No

Multiple Sclerosis

Yes
No

Crohns Disease

Yes
No

Obsessive/Compulsive Disorder

Yes
No

Depression

Yes
No

Obesity

Yes
No

Diabetes

Yes
No

Osteoarthritis

Yes
No

Dementia

Yes
No

Osteoporosis

Yes
No

Eating Disorders

Yes
No

Rheumatoid Arthritis

Yes
No

Elevated Lipids/Cholesterol

Yes
No

Rhinitis

Yes
No

Epilepsy

Yes
No

Spina Bifida

Yes
No

Anxiety

Yes
No

Schizophrenia

Yes
No

Parkinson Disease

Yes
No

Suicidal Tendencies

Yes
No

Stroke/Haemorrhage

Yes
No

Thyroid Disorder

Yes
No

High Blood Pressure

Yes
No

Others

Kidney Disease

Yes
No

Have any other relatives in your family suffered from any of the above disorders? (Details)

Would you be willing to answer a question concerning your family history? YES/NO If so, in what country(s) were your grandparents born?

Would you be willing to be involved in gene research into the cause of any of these disorders? This would involve donating one blood sample and filling out a single questionnaire?

Yes
No