Family History Questionnaire - Hopkins Medicine
|Relationship to you |Sex |Diagnosis (check all that apply) |Treatment (check all that apply if known) |
| |( Male |( Major depression |( Other:____________ |( therapy/counseling |
| |( Female |( Bipolar disorder | |( medication |
| | |( Anxiety disorder |___________________ |( hospitalization |
| |( Male |( Major depression |( Other:____________ |( therapy/counseling |
| |( Female |( Bipolar disorder | |( medication |
| | |( Anxiety disorder |___________________ |( hospitalization |
| |( Male |( Major depression |( Other:____________ |( therapy/counseling |
| |( Female |( Bipolar disorder | |( medication |
| | |( Anxiety disorder |___________________ |( hospitalization |
| |( Male |( Major depression |( Other:____________ |( therapy/counseling |
| |( Female |( Bipolar disorder | |( medication |
| | |( Anxiety disorder |___________________ |( hospitalization |
1) Have any of your blood relatives been diagnosed with a mental illness? (Yes (No If yes, please indicate their sex, relationship to you, and if known, diagnosis and treatment:
2) Have any of your female blood relatives suffered from mental illness within a year of giving birth?(Yes (No If yes, please indicate below:
|Relationship to you |Diagnosis (check all that apply) |
|( Mother |( Major depression |
|( Sister |( Bipolar disorder |
|( Father’s mother |( Anxiety disorder |
|( Mother’s mother |( Other: |
|( Cousin from mother’s side | |
|( Cousin from father’s side | |
|( Aunt from mother’s side | |
|( Aunt from father’s side | |
|( Mother |( Major depression |
|( Sister |( Bipolar disorder |
|( Father’s mother |( Anxiety disorder |
|( Mother’s mother |( Other: |
|( Cousin from mother’s side | |
|( Cousin from father’s side | |
|( Aunt from mother’s side | |
|( Aunt from father’s side | |
|( Mother |( Major depression |
|( Sister |( Bipolar disorder |
|( Father’s mother |( Anxiety disorder |
|( Mother’s mother |( Other: |
|( Cousin from mother’s side | |
|( Cousin from father’s side | |
|( Aunt from mother’s side | |
|( Aunt from father’s side | |
3) Have any of your blood relatives committed suicide? (Yes (No If yes, please list their sex, relationship to you and age at suicide:
|Relationship to you |Sex |Age at suicide |
| |( Male ( Female | |
| |( Male ( Female | |
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Clinician Use Only
Patient _________
Interview Date_________
WMDC Consult
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