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Form: 01Vers:03ID#:SIS OMB No. 09250522FAMILY HISTORY QUESTIONNAIRE V3 Please give your completed form to the MSI examiner. Instructions: Use the enclosed pen or any DARK BLUE OR BLACK BALLPOINT PEN.
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How to fill out family history questionnaire

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How to fill out family history questionnaire

01
Gather information about your immediate family members, such as parents and siblings.
02
Collect details about their medical conditions, including any chronic diseases or genetic disorders they may have.
03
Note down the ages at which they were diagnosed with these conditions, if applicable.
04
Find out if any family members have had serious illnesses, surgeries, or hospitalizations.
05
Include information about any significant medications or treatments that family members are currently undergoing.
06
Provide accurate information about the cause of death and age at death for any deceased family members.
07
Fill out the questionnaire completely and honestly, ensuring you don't omit any relevant information.
08
Review the completed questionnaire for accuracy and make any necessary updates if new information arises.

Who needs family history questionnaire?

01
Individuals who are seeking medical care and want to provide their healthcare provider with a comprehensive understanding of their family's medical history.
02
People who have a family history of certain diseases or conditions that may have a hereditary component.
03
Individuals who want to assess their own risk factors for certain health conditions based on their family's medical history.
04
Those who are participating in medical research studies or genetic testing programs that require detailed family history information.
05
Individuals who want to create a record of their family's medical history for future reference or to share with other family members.
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The family history questionnaire is a form that collects information about the medical history of an individual's family members to identify any potential health risks or hereditary conditions.
Typically, individuals are required to fill out a family history questionnaire, especially when seeking medical treatment or participating in research studies.
To fill out a family history questionnaire, individuals need to provide accurate information about their family members' medical history, including any known illnesses, conditions, or genetic disorders.
The purpose of the family history questionnaire is to help healthcare providers assess an individual's risk for certain diseases or conditions based on their family's medical history.
Information that must be reported on a family history questionnaire includes details about the health conditions, diseases, or genetic disorders that have affected family members.
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