Sample Family Health History Form for Federally-Qualified ...
Family Health History
Have any of your close blood relatives (grandparents, parents, brothers, sisters, children) ever had the following?
|Disease |Yes |No |Which Relative? |Age at Diagnosis |
|High Blood Pressure | | | | |
|Heart Disease | | | | |
|Diabetes | | | | |
|Stroke | | | | |
|Asthma | | | | |
|Breast Cancer | | | | |
|Colon or Rectal Cancer | | | | |
|Other type of Cancer: | | | | |
|Please list_______________ | | | | |
|Mental Problem | | | | |
|(depression, bipolar, schizophrenia) | | | | |
|Alcohol or Drug Problem | | | | |
|Other diseases that run in your family: Please list | | | | |
| | | | | |
|_________________________ | | | | |
| |___ | |_______________________ |_________ |
|_________________________ | | | | |
| |___ | |_______________________ |_________ |
|_________________________ | | | | |
| |___ | |_______________________ |_________ |
|_________________________ | | | | |
| |___ | |_______________________ |_________ |
................
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