Family History Assessment Form

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What is Family History Assessment Form?

The Family History Assessment Form is a document used to gather information about a person's family medical history. It helps healthcare providers understand any hereditary conditions or patterns in the family that may affect an individual's health.

What are the types of Family History Assessment Form?

There are several types of Family History Assessment Forms tailored for different medical specialties and purposes. Some common types include:

General Family History Form
Pediatric Family History Form
Cardiovascular Family History Form
Cancer Family History Form
Mental Health Family History Form

How to complete Family History Assessment Form

Completing a Family History Assessment Form is an important step in providing a comprehensive medical history. Here are some tips to help you fill out the form accurately:

01
Gather information about immediate family members (parents, siblings, children)
02
Include details about any medical conditions or diseases they have been diagnosed with
03
Note any surgeries or procedures family members have undergone
04
Provide information about lifestyle factors that may impact health (smoking, alcohol use, etc.)
05
Be thorough and honest when filling out the form

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Video Tutorial How to Fill Out Family History Assessment Form

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Questions & answers

A family history (PDF) is a lifetime record that patients should provide to all their new physicians when receiving health care. The history should be detailed, including: First-, 2nd- and 3rd-degree relatives. Age for all relatives (age at time of death for the deceased)
Ask questions like: How old are you? Do you or did anyone in our family have any long-term health problems, like heart disease, diabetes, kidney disease, bleeding disorder, or lung disease? Do you or did anyone in our family have any health issues like high blood pressure, high cholesterol, or asthma?
But a family history can take many forms, including the following: A record of your family with you as a child, containing recollections of your parents and other living ancestors. A record of your family with you as a parent, containing recollections of your children and your other descendants.
A family health history can identify people with a higher-than-usual chance of having common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and type 2 diabetes. These complex disorders are influenced by a combination of genetic factors, environmental conditions, and lifestyle choices.
Include information on major medical conditions, causes of death, age at disease diagnosis, age at death, and ethnic background. Be sure to update the information regularly and share what you've learned with your family and with your doctor.
Questions to Ask Your Family about Their Health History Does anyone in our family have cancer? Does anyone in our family have a chronic disease? Does our family have a history of mental health conditions? When did family members get diagnosed with a serious or chronic disease? Share details with your physician.
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