FINAL- Your Family Medical History Questionnaire

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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