Your
Family
Medical
History
Questionnaire
 




Even
if
you’re
healthy
now,
knowing
your
family
health
history
will

provide
important
clues
to
your
future
health
and
the
future

health
of
your
family.
Do
certain
diseases
and
health
conditions

run
in
your
family?
If
you’re
unsure,
begin
collecting
your
family

health
history
today
by
using
this
easy
to
follow
questionnaire
and
checklist.



You
may
feel
uncomfortable
asking
for
personal
health
information
from
some
family
members,
but
it’s

important
to
try.
Pick
a
time
when
you’re
less
likely
to
get
interrupted
so
your
discussion
can
be
more

relaxed.
And,
remember,
older
relatives
(and
even
younger
relatives)
may
not
use
the
same
health

terms
as
you
do,
so
be
aware
to
listen
for
clues
about
how
they
might
describe
a
relative’s
behavior
or

health
history.
For
example,
“Grandmother
always
spent
about
a
week
in
bed
in
the
dark
each
month,”

could
indicate
that
she
suffered
from
menstrual
migraines.



The
information
you
gather
will
help
you
and
your
health
care
provider
determine
what
health
problems

you
may
be
at
increased
risk
for
in
the
future
so
that
you
can
take
action
today
to
lower
those
risks.
At

HealthyWomen,
we
want
you
to
live
the
longest,
healthiest
life
possible.
This
Family
Medical
History

Questionnaire
can
help
you
do
just
that.


ALL
ABOUT
YOU

Your
name:
 List
any
questions
or
concerns
you
may
have

Date
of
birth:
 about
your
medical
history:

Blood
type:
 

Ethnic
origin:
 


 

Known
health
problems:
 Onset
 


 age:
 

❑ Alcohol
and/or
drug
abuse

 

❑ Allergies
 

❑ Asthma
 

❑ Cancer
If
yes,
what
kind?

___________________
 List
any
lifestyle
or
environmental
factors

❑ Depression
 related
to
your
health
and
wellness:

❑ Diabetes
 

❑ Heart
disease
 

❑ High
blood
pressure
 

❑ High
cholesterol
 

❑ Mental
Illness
 

❑ Stroke
 

❑ Other

_________________________________________
 

❑ Other

_________________________________________
 

Do
you
smoke?

❑ Yes



❑ No
 Do
you
take
risks
with
your
health,
such
as,

If
yes,
cigarettes
smoked
per
day:







_______________________
 abuse
drugs
and
alcohol,
drive
over
the
speed

If
yes,
totals
years
as
a
smoker:












_______________________
 limit,
not
wear
a
seat
belt
or
have
multiple


 sexual
partners
or
unprotected
sex?

How
often
do
you
experience
stress:

_______________________
 ❑ Yes



❑ No





If
yes,
please
describe:



 

Do
you
get
regular
physical
activity?

❑ Yes



❑ No

If
yes,
how
often?

_____________________________________________



Is
your
diet
healthy
and
balanced?





❑ Yes



❑ No




For
more
health
and
wellness
information,
visit
www.HealthyWomen.org

ALL
ABOUT
YOUR
PARENTS

Fill
out
the
forms
below
with
your
biological
(birth)
parents’
information
(living
and
deceased).



Name:
 Name:

Relationship:
 Relationship:

Date
of
birth:
 Date
of
birth:

Blood
type:
 Blood
type:

Ethnic
origin:
 Ethnic
origin:


 

Known
health
problems:
 Onset
age:
 Known
health
problems:
 Onset
age:


 

❑ Alcohol
and/or
drug
abuse

 ❑ Alcohol
and/or
drug
abuse


❑ Allergies
 ❑ Allergies

❑ Asthma
 ❑ Asthma

❑ Cancer

 ❑ Cancer


If
yes,
what
kind?

 If
yes,
what
kind?


_______________________________________
 _______________________________________

❑ Depression
 ❑ Depression

❑ Diabetes
 ❑ Diabetes

❑ Heart
disease
 ❑ Heart
disease

❑ High
blood
pressure
 ❑ High
blood
pressure

❑ High
cholesterol
 ❑ High
cholesterol

❑ Mental
Illness
 ❑ Mental
Illness

❑ Stroke
 ❑ Stroke

❑ Other

___________________________
 ❑ Other

___________________________

❑ Other

___________________________
 ❑ Other

___________________________

❑ Other

___________________________
 ❑ Other

___________________________



 

Does
he
or
she
smoke?

❑ Yes



❑ No
 Does
he
or
she
smoke?

❑ Yes



❑ No


 

Is
he
or
she
deceased?


❑ Yes



❑ No
 Is
he
or
she
deceased?


❑ Yes



❑ No

If
yes,
at
what
age?







______________________
 If
yes,
at
what
age?







______________________

If
yes,
of
what
cause?



______________________
 If
yes,
of
what
cause?



______________________


 

List
any
questions
or
concerns
you
may
have
 List
any
questions
or
concerns
you
may
have

about
their
medical
history:
 about
their
medical
history:


 






































For
more
health
and
wellness
information,
visit
www.HealthyWomen.org

 ALL
ABOUT
YOUR
SIBLINGS

Fill
out
the
forms
below
with
your
siblings’
information
(living
and
deceased).



Name:
 Name:
 Name:


Relationship:
 Relationship:
 Relationship:

Date
of
birth:
 Date
of
birth:
 Date
of
birth:


 
 

Known
health
problems:
 Onset
 Known
health
problems:
 Onset
 Known
health
problems:
 Onset


 age:
 
 age:
 
 age:

❑ Alcohol
and/or
drug
abuse




 ❑ Alcohol
and/or
drug
abuse




 ❑ Alcohol
and/or
drug
abuse





❑ Allergies
 ❑ Allergies
 ❑ Allergies

❑ Asthma
 ❑ Asthma
 ❑ Asthma

❑ Cancer
 ❑ Cancer
 ❑ Cancer

❑ Depression
 ❑ Depression
 ❑ Depression

❑ Diabetes
 ❑ Diabetes
 ❑ Diabetes

❑ Heart
disease
 ❑ Heart
disease
 ❑ Heart
disease

❑ High
blood
pressure
 ❑ High
blood
pressure
 ❑ High
blood
pressure

❑ High
cholesterol
 ❑ High
cholesterol
 ❑ High
cholesterol

❑ Mental
Illness
 ❑ Mental
Illness
 ❑ Mental
Illness

❑ Stroke
 ❑ Stroke
 ❑ Stroke

❑ Other

________________________
 ❑ Other

________________________
 ❑ Other

________________________

❑ Other

________________________
 ❑ Other

________________________
 ❑ Other

________________________

❑ Other

________________________
 ❑ Other

________________________
 ❑ Other

________________________


 
 


 
 

Does
he
or
she
smoke?

❑ Yes



❑ No
 Does
he
or
she
smoke?

❑ Yes



❑ No
 Does
he
or
she
smoke?

❑ Yes



❑ No


 
 

Is
he
or
she
deceased?


❑ Yes



❑ No
 Is
he
or
she
deceased?


❑ Yes



❑ No
 Is
he
or
she
deceased?


❑ Yes



❑ No

If
yes,
at
what
age?







______________________
 If
yes,
at
what
age?







______________________
 If
yes,
at
what
age?







______________________

If
yes,
of
what
cause?



______________________
 If
yes,
of
what
cause?



______________________
 If
yes,
of
what
cause?



______________________


 
 

List
any
questions
or
concerns
you
may
 List
any
questions
or
concerns
you
may
 List
any
questions
or
concerns
you
may

have
about
their
medical
history:
 have
about
their
medical
history:
 have
about
their
medical
history:


 
 


 


 


 








































For
more
health
and
wellness
information,
visit
www.HealthyWomen.org

ALL
ABOUT
YOUR
GRANDPARENTS

Fill
out
the
forms
below
with
your
paternal
grandparents’
information
(living
and
deceased).



Name:
 Name:

Relationship:
 Relationship:

Date
of
birth:
 Date
of
birth:

Ethnic
origin:
 Ethnic
origin:


 

Known
health
problems:
 Onset
age:
 Known
health
problems:
 Onset
age:


 

❑ Alcohol
and/or
drug
abuse

 ❑ Alcohol
and/or
drug
abuse


❑ Allergies
 ❑ Allergies

❑ Asthma
 ❑ Asthma

❑ Cancer

 ❑ Cancer


If
yes,
what
kind?

 If
yes,
what
kind?


_______________________________________
 _______________________________________

❑ Depression
 ❑ Depression

❑ Diabetes
 ❑ Diabetes

❑ Heart
disease
 ❑ Heart
disease

❑ High
blood
pressure
 ❑ High
blood
pressure

❑ High
cholesterol
 ❑ High
cholesterol

❑ Mental
Illness
 ❑ Mental
Illness

❑ Stroke
 ❑ Stroke

❑ Other

___________________________
 ❑ Other

___________________________

❑ Other

___________________________
 ❑ Other

___________________________

❑ Other

___________________________
 ❑ Other

___________________________



 

Does
he
or
she
smoke?

❑ Yes



❑ No
 Does
he
or
she
smoke?

❑ Yes



❑ No


 

Is
he
or
she
deceased?


❑ Yes



❑ No
 Is
he
or
she
deceased?


❑ Yes



❑ No

If
yes,
at
what
age?







______________________
 If
yes,
at
what
age?







______________________

If
yes,
of
what
cause?



______________________
 If
yes,
of
what
cause?



______________________


 

List
any
questions
or
concerns
you
may
have
 List
any
questions
or
concerns
you
may
have

about
their
medical
history:
 about
their
medical
history:


 








































For
more
health
and
wellness
information,
visit
www.HealthyWomen.org

ALL
ABOUT
YOUR
GRANDPARENTS

Fill
out
the
forms
below
with
your
maternal
grandparents’
information
(living
and
deceased).



Name:
 Name:

Relationship:
 Relationship:

Date
of
birth:
 Date
of
birth:

Ethnic
origin:
 Ethnic
origin:


 

Known
health
problems:
 Onset
age:
 Known
health
problems:
 Onset
age:


 

❑ Alcohol
and/or
drug
abuse

 ❑ Alcohol
and/or
drug
abuse


❑ Allergies
 ❑ Allergies

❑ Asthma
 ❑ Asthma

❑ Cancer

 ❑ Cancer


If
yes,
what
kind?

 If
yes,
what
kind?


_______________________________________
 _______________________________________

❑ Depression
 ❑ Depression

❑ Diabetes
 ❑ Diabetes

❑ Heart
disease
 ❑ Heart
disease

❑ High
blood
pressure
 ❑ High
blood
pressure

❑ High
cholesterol
 ❑ High
cholesterol

❑ Mental
Illness
 ❑ Mental
Illness

❑ Stroke
 ❑ Stroke

❑ Other

___________________________
 ❑ Other

___________________________

❑ Other

___________________________
 ❑ Other

___________________________

❑ Other

___________________________
 ❑ Other

___________________________



 

Does
he
or
she
smoke?

❑ Yes



❑ No
 Does
he
or
she
smoke?

❑ Yes



❑ No


 

Is
he
or
she
deceased?

❑ Yes



❑ No
 Is
he
or
she
deceased?

❑ Yes



❑ No

If
yes,
at
what
age?







______________________
 If
yes,
at
what
age?







______________________

If
yes,
of
what
cause?



______________________
 If
yes,
of
what
cause?



______________________


 

List
any
questions
or
concerns
you
may
have
 List
any
questions
or
concerns
you
may
have

about
their
medical
history:
 about
their
medical
history:


 







































For
more
health
and
wellness
information,
visit
www.HealthyWomen.org