FINAL- Your Family Medical History Questionnaire
[Pages:5]YourFamilyMedicalHistoryQuestionnaire
Evenifyou'rehealthynow,knowingyourfamilyhealthhistorywill provideimportantcluestoyourfuturehealthandthefuture healthofyourfamily.Docertaindiseasesandhealthconditions runinyourfamily?Ifyou'reunsure,begincollectingyourfamily healthhistorytodaybyusingthiseasytofollowquestionnaireandchecklist.
Youmayfeeluncomfortableaskingforpersonalhealthinformationfromsomefamilymembers,butit's importanttotry.Pickatimewhenyou'relesslikelytogetinterruptedsoyourdiscussioncanbemore relaxed.And,remember,olderrelatives(andevenyoungerrelatives)maynotusethesamehealth termsasyoudo,sobeawaretolistenforcluesabouthowtheymightdescribearelative'sbehavioror healthhistory.Forexample,"Grandmotheralwaysspentaboutaweekinbedinthedarkeachmonth," couldindicatethatshesufferedfrommenstrualmigraines.
Theinformationyougatherwillhelpyouandyourhealthcareproviderdeterminewhathealthproblems youmaybeatincreasedriskforinthefuturesothatyoucantakeactiontodaytolowerthoserisks.At HealthyWomen,wewantyoutolivethelongest,healthiestlifepossible.ThisFamilyMedicalHistory Questionnairecanhelpyoudojustthat.
ALLABOUTYOU
Yourname:
Dateofbirth:
Bloodtype:
Ethnicorigin:
Knownhealthproblems:
Onset
age:
Alcoholand/ordrugabuse
Allergies
Asthma
CancerIfyes,whatkind?___________________ Depression
Diabetes Heartdisease Highbloodpressure
Highcholesterol MentalIllness
Stroke
Other_________________________________________ Other_________________________________________
Doyousmoke? Yes No
Ifyes,cigarettessmokedperday:_______________________
Ifyes,totalsyearsasasmoker:_______________________
Howoftendoyouexperiencestress:_______________________
Doyougetregularphysicalactivity? Yes No
Ifyes,howoften?_____________________________________________
Isyourdiethealthyandbalanced? Yes No
Listanyquestionsorconcernsyoumayhave aboutyourmedicalhistory: Listanylifestyleorenvironmentalfactors relatedtoyourhealthandwellness: Doyoutakeriskswithyourhealth,suchas, abusedrugsandalcohol,driveoverthespeed limit,notwearaseatbeltorhavemultiple sexualpartnersorunprotectedsex?
Yes NoIfyes,pleasedescribe:
Formorehealthandwellnessinformation,visit
ALLABOUTYOURPARENTS
Fillouttheformsbelowwithyourbiological(birth)parents'information(livinganddeceased).
Name:
Relationship:
Dateofbirth:
Bloodtype:
Ethnicorigin:
Knownhealthproblems:
Alcoholand/ordrugabuse Allergies Asthma Cancer
Ifyes,whatkind?
_______________________________________
Depression Diabetes Heartdisease Highbloodpressure Highcholesterol MentalIllness Stroke Other___________________________ Other___________________________ Other___________________________
Onsetage:
Name:
Relationship:
Dateofbirth:
Bloodtype:
Ethnicorigin:
Knownhealthproblems:
Alcoholand/ordrugabuse Allergies Asthma Cancer
Ifyes,whatkind?
_______________________________________
Depression Diabetes Heartdisease Highbloodpressure Highcholesterol MentalIllness Stroke Other___________________________ Other___________________________ Other___________________________
Onsetage:
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________ Ifyes,ofwhatcause?______________________ Listanyquestionsorconcernsyoumayhave abouttheirmedicalhistory:
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________ Ifyes,ofwhatcause?______________________ Listanyquestionsorconcernsyoumayhave abouttheirmedicalhistory:
Formorehealthandwellnessinformation,visit
ALLABOUTYOURSIBLINGS
Fillouttheformsbelowwithyoursiblings'information(livinganddeceased).
Name:
Relationship:
Dateofbirth:
Knownhealthproblems:
Onset
age:
Alcoholand/ordrugabuse Allergies
Asthma Cancer Depression
Diabetes Heartdisease
Highbloodpressure
Highcholesterol MentalIllness
Stroke Other________________________
Other________________________
Other________________________
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________
Ifyes,ofwhatcause?______________________
Listanyquestionsorconcernsyoumay
haveabouttheirmedicalhistory:
Name:
Relationship:
Dateofbirth:
Knownhealthproblems:
Onset
age:
Alcoholand/ordrugabuse Allergies
Asthma Cancer Depression
Diabetes Heartdisease
Highbloodpressure
Highcholesterol MentalIllness
Stroke Other________________________
Other________________________
Other________________________
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________
Ifyes,ofwhatcause?______________________
Listanyquestionsorconcernsyoumay
haveabouttheirmedicalhistory:
Name:
Relationship:
Dateofbirth:
Knownhealthproblems:
Onset
age:
Alcoholand/ordrugabuse Allergies
Asthma Cancer Depression
Diabetes Heartdisease
Highbloodpressure
Highcholesterol MentalIllness
Stroke Other________________________
Other________________________
Other________________________
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________
Ifyes,ofwhatcause?______________________
Listanyquestionsorconcernsyoumay
haveabouttheirmedicalhistory:
Formorehealthandwellnessinformation,visit
ALLABOUTYOURGRANDPARENTS
Fillouttheformsbelowwithyourpaternalgrandparents'information(livinganddeceased).
Name:
Relationship:
Dateofbirth:
Ethnicorigin:
Knownhealthproblems:
Alcoholand/ordrugabuse Allergies Asthma Cancer
Ifyes,whatkind?
_______________________________________
Depression Diabetes Heartdisease Highbloodpressure Highcholesterol MentalIllness Stroke Other___________________________ Other___________________________ Other___________________________
Onsetage:
Name:
Relationship:
Dateofbirth:
Ethnicorigin:
Knownhealthproblems:
Alcoholand/ordrugabuse Allergies Asthma Cancer
Ifyes,whatkind?
_______________________________________
Depression Diabetes Heartdisease Highbloodpressure Highcholesterol MentalIllness Stroke Other___________________________ Other___________________________ Other___________________________
Onsetage:
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________ Ifyes,ofwhatcause?______________________ Listanyquestionsorconcernsyoumayhave abouttheirmedicalhistory:
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________ Ifyes,ofwhatcause?______________________ Listanyquestionsorconcernsyoumayhave abouttheirmedicalhistory:
Formorehealthandwellnessinformation,visit
ALLABOUTYOURGRANDPARENTS
Fillouttheformsbelowwithyourmaternalgrandparents'information(livinganddeceased).
Name:
Relationship:
Dateofbirth:
Ethnicorigin:
Knownhealthproblems:
Alcoholand/ordrugabuse Allergies Asthma Cancer
Ifyes,whatkind?
_______________________________________
Depression Diabetes Heartdisease Highbloodpressure Highcholesterol MentalIllness Stroke Other___________________________ Other___________________________ Other___________________________
Onsetage:
Name:
Relationship:
Dateofbirth:
Ethnicorigin:
Knownhealthproblems:
Alcoholand/ordrugabuse Allergies Asthma Cancer
Ifyes,whatkind?
_______________________________________
Depression Diabetes Heartdisease Highbloodpressure Highcholesterol MentalIllness Stroke Other___________________________ Other___________________________ Other___________________________
Onsetage:
Doesheorshesmoke? Yes No
Doesheorshesmoke? Yes No
Isheorshedeceased? Yes No
Isheorshedeceased? Yes No
Ifyes,atwhatage?______________________
Ifyes,atwhatage?______________________
Ifyes,ofwhatcause?______________________
Ifyes,ofwhatcause?______________________
Listanyquestionsorconcernsyoumayhave
Listanyquestionsorconcernsyoumayhave
abouttheirmedicalhistory:
abouttheirmedicalhistory:
Formorehealthandwellnessinformation,visit
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