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INITIAL HEALTH HISTORY Patient Name FAMILY HISTORY:DateDo you feel that your family history has had an affect on your current condition? Yes No If yes, explain why ___ Are your parents alive?YesNoIf

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How to fill out your family medical history

01

Gather information about your immediate family members including parents, siblings, and children.

02

Create a list of medical conditions or diseases that relatives have been diagnosed with.

03

Include any information on chronic conditions, mental health issues, and significant surgeries.

04

Document the age at which each family member was diagnosed with a particular condition.

05

Update the family medical history regularly as new information becomes available.

Who needs your family medical history?

01

Healthcare providers such as doctors, nurses, and genetic counselors rely on family medical history to assess a patient's risk for certain conditions.

02

Individuals with a family history of hereditary diseases or conditions may use this information to make informed decisions about their health and treatment options.

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What is your family medical history?

Your family medical history is a record of health information about you and your close relatives. It includes information on illnesses, treatments, and any genetic conditions that may affect your health.

Who is required to file your family medical history?

Typically, healthcare providers may require patients to fill out their family medical history forms, especially during initial consultations or screenings.

How to fill out your family medical history?

To fill out your family medical history, gather information about your relatives’ health conditions, ages, causes of death, and any pertinent genetic disorders. Fill out the form or template provided by your healthcare provider, ensuring accuracy and thoroughness.

What is the purpose of your family medical history?

The purpose of your family medical history is to help healthcare providers assess your risk of developing certain health conditions, guide preventive care decisions, and tailor treatment plans.

What information must be reported on your family medical history?

Required information typically includes the health conditions of immediate and extended family members, ages at diagnosis, any significant health events, and relevant genetic information.

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