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Family History Questionnaire Name: Date: Instructions: Please circle Y to those that apply to YOU and/or YOUR FAMILY(on both your mother OR fathers side). Behind each statement, please list the relationship

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How to fill out family history questionnaire

01

Step 1: Start by gathering information about your immediate family members, including parents, siblings, and children. Make a list of their names, birthdates, and any significant medical conditions or diseases they have been diagnosed with.

02

Step 2: Move on to the extended family members such as grandparents, aunts, uncles, and cousins. Collect the same information mentioned above for each individual.

03

Step 3: Once you have all the information, you can either fill out a paper form if provided or use an online family history questionnaire tool.

04

Step 4: Begin by entering your own personal details and medical history as the first individual on the form.

05

Step 5: Continue by entering the information of each family member, one by one, in the order of their relation to you.

06

Step 6: Provide accurate information about any medical conditions or diseases that each family member has been diagnosed with. If you are unsure about certain details, try to gather more information from other relatives or medical records.

07

Step 7: Double-check all the information you have entered to ensure its accuracy. Make any necessary corrections or additions.

08

Step 8: Once you are satisfied with the completeness and accuracy of the filled questionnaire, save or submit it as per the given instructions.

09

Step 9: Keep a copy of the completed family history questionnaire for your records and share the information with your healthcare provider during medical appointments.

Who needs family history questionnaire?

01

Anyone who wants to understand their risk factors for certain diseases or conditions based on their family history needs a family history questionnaire. It is particularly important for individuals with a family history of hereditary conditions, chronic diseases, or certain types of cancers. Healthcare providers may also request patients to fill out a family history questionnaire to assess their risk and develop personalized treatment plans.

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What is family history questionnaire?

A family history questionnaire is a form that gathers information about an individual's family medical history.

Who is required to file family history questionnaire?

Individuals who are asked to provide information about their family medical history are required to file a family history questionnaire.

How to fill out family history questionnaire?

To fill out a family history questionnaire, provide accurate information about family members' medical conditions, diseases, and genetic predispositions.

What is the purpose of family history questionnaire?

The purpose of a family history questionnaire is to assess an individual's risk for certain health conditions based on their family medical history.

What information must be reported on family history questionnaire?

Information such as family members' medical conditions, illnesses, age at diagnosis, and any genetic conditions should be reported on a family history questionnaire.

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