21.  The names, addresses, and dates of birth of all siblings: __________________________________________________________
__________________________________________________________
__________________________________________________________
        
22.  If your parents are deceased, state the date, place, and cause: __________________________________________________________
__________________________________________________________
__________________________________________________________

23.  Name and address of the doctor or institution which prescribed DES:
__________________________________________________________
__________________________________________________________
__________________________________________________________

24.  State whether the doctor or institution referred to in #23 has been contacted. 
If so, state the date thereof, the manner of such contact, and the results:
___________________________________________________________
___________________________________________________________
___________________________________________________________

25.  State whether the pharmacy which filled the prescription of DES was contacted. 
If so, state the name and address of the pharmacy and/or the name
and address of the pharmacist, the date of contact, and the results thereof:
___________________________________________________________
___________________________________________________________
___________________________________________________________

26.  State all DES-related injuries, conditions, operations, biopsies, or any
other treatment received as a result of the injuries sustained by reason of DES:
___________________________________________________________
___________________________________________________________
___________________________________________________________