CATRDR Community Health Registry Form

CATRDR Community Health & Ancestral Disease Mapping Service

Individual Registration Form

This registry helps CATRDR map diseases within families, communities, and regions.

We collect basic health information and ancestral lineage data to understand patterns of rare, chronic, and inherited conditions.

Your information will help future research, early detection, and targeted regenerative medicine programmes.

Your data is confidential, securely stored, and may only be used for research, mapping, and approved clinical initiatives.

A. Personal Information

1. Full Name

2. Date of Birth

3. Gender

4. Country of Residence

5. City / Town / Village

6. Primary Language Spoken

7. Mobile / WhatsApp Number

Include country code (e.g., +44, +91)

8. Email Address

B. Ancestral / Lineage Data

9. Your Ancestral Origin

Ethnic / Tribal / Regional lineage

10. Country / Region your father's family originates from

11. Country / Region your mother's family originates from

12. Are your parents related by blood (consanguinity)?

No

Yes – first cousins

Yes – second cousins

Yes – distant relatives

Not sure

Prefer not to say

13. Are you aware of any common hereditary conditions in your family lineage?

Yes

No

Not sure

Please list known family conditions:

C. Your Health & Family Health Information

14. Do you currently have any diagnosed health condition(s)?

Yes

No

Not sure

Please provide details:

16. Do any of the following apply to your extended family?

Multiple family members with the same rare/chronic disease

Early deaths (under 50) from unknown causes

Children born with congenital conditions

Genetic or inherited illnesses known in community

None of the above

Not sure

D. Community-Level Disease Patterns

18. Are there clusters of similar illnesses in your wider community or relatives?

Yes

No

Not sure

E. Lifestyle & Demographic Information

19. Marital Status

20. Number of children (if any)

21. Do you smoke or use tobacco?

22. Do you consume alcohol?

23. Occupation

24. Household size (how many people live with you?)

F. Interest in Future Programmes

25. Would you like to participate in: (Tick all that apply)

Community disease-mapping studies

Rare disease screening

Genetic or ancestry testing

Regenerative medicine research

Clinical trials (if eligible)

Only want to be informed, not participate

G. Consent & Verification

Signature / Digital Confirmation

By typing your name, you are signing this form digitally.