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Family History Questionnaire for Common Hereditary Cancer Syndromes Patient Name: Physician: Date of Birth: Date completed: Instructions: Please circle Y to those that apply to YOU and/or YOUR FAMILY
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How to fill out family history questionnaire for

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How to fill out a family history questionnaire:

01
Begin by carefully reading the instructions: Familiarize yourself with the questionnaire before starting to ensure you understand the purpose and any specific guidelines provided.
02
Gather relevant information: Collect the necessary details about your family's medical history. This includes information about immediate family members (parents, grandparents, siblings), such as any diagnosed medical conditions, diseases, or genetic disorders they may have had.
03
Provide accurate information: Fill in the questionnaire with accurate and up-to-date information. Be precise about the types of illnesses or conditions your family members had, the age at which they were diagnosed, and any information about their treatments or outcomes.
04
Include additional information: If the questionnaire allows for it, feel free to add any relevant information or details that may be important. This could include specific medical tests, surgeries, or lifestyle factors that may have contributed to a family member's condition.
05
Consult family members if necessary: If you are unsure of certain details, reach out to family members and discuss their medical history. This can help fill any gaps in your knowledge and provide a more comprehensive picture.
06
Review and double-check: Before submitting the questionnaire, review all the information you have provided. Ensure there are no errors or omissions that could impact the accuracy of the report.

Who needs a family history questionnaire?

01
Individuals visiting healthcare professionals: When visiting doctors, nurses, or other healthcare providers, they may request patients to fill out a family history questionnaire. This helps healthcare professionals assess the risk of certain diseases or disorders that may have a genetic component.
02
Those participating in research studies: Research studies often require participants to provide information about their family medical history. This data helps researchers understand patterns, genetic predispositions, and potential risk factors for various conditions.
03
Individuals seeking health insurance: In some cases, health insurance companies may require applicants to complete a family history questionnaire. This is done to evaluate the potential risks of insuring individuals with certain genetic or hereditary conditions.
In conclusion, filling out a family history questionnaire involves gathering accurate information about your family's medical history and providing it in a thorough and detailed manner. These questionnaires are typically required by healthcare professionals, research studies, and health insurance companies to assess the risk of certain conditions.
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The family history questionnaire is used to gather information about a person's family medical history.
Anyone who is requested to provide their family medical history by a healthcare provider or insurance company may be required to fill out a family history questionnaire.
To fill out a family history questionnaire, one should provide details about their relatives' health conditions, diseases, and age of onset. It is important to be as accurate and thorough as possible.
The purpose of the family history questionnaire is to assess the risk of developing certain diseases based on genetic predisposition and family medical history.
Information such as the health conditions, diseases, and age of onset of the person's relatives must be reported on the family history questionnaire.
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