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Family History Questionnaire
  Forms must be completed/ submitted prior to leaving our website

Forms must be completed/ submitted prior to leaving our website

1.  Today’s Date

1. Today’s Date


2.  Name

2. Name


3.  Age

3. Age


4.  Address

4. Address


5.  Physician's Fax Number for Copy of Consult Summary

5. Physician's Fax Number for Copy of Consult Summary

If you do not have this available, please provide physician's phone number, and indicate that this is the phone. no.   

6.  Religion

6. Religion


7.  Ethnicity (eg: Ashkenazi Jewish, French, American Indian, etc.)

7. Ethnicity (eg: Ashkenazi Jewish, French, American Indian, etc.)




8.  Are you adopted?

8. Are you adopted?


9.  List all of your children and their ages (including any deceased)

9. List all of your children and their ages (including any deceased)

ex: Mary 32, Paul 45, Joe (died at age 46), also one stillbirth

10.  List all of your brothers and sisters and ages (incl deceased)

10. List all of your brothers and sisters and ages (incl deceased)

ex: Mary 60, Robert died at 50 of lung cancer (smoker) 

11.  On your mother's side, is there a history of any of the following?

11. On your mother's side, is there a history of any of the following?

Down syndrome, spina bifida, mental retardation, Fragile-X syndrome, brain abnormalities (anencephaly, hydrocephaly), Neurofibromatosis, birthmarks, muscular dystrophy/ muscle disease, seizures/ epilepsy, blindness, deafness, Huntington's disease, Tay Sach's disease or any other neurologic condition. Who is affected?

12.  On your father's side, is there a history of any of the following?

12. On your father's side, is there a history of any of the following?

Down syndrome, spina bifida, mental retardation, Fragile-X syndrome, brain abnormalities (anencephaly, hydrocephaly), Neurofibromatosis, birthmarks, muscular dystrophy/ muscle disease, seizures/ epilepsy, blindness, deafness, Huntington's disease, Tay Sach's disease or any other neurologic condition. Who is affected?

13.  Does your partner/spouse have a family history of the following?

13. Does your partner/spouse have a family history of the following?

As listed above.  Who is affected?

14.  On your mother's side, is there a history of any of the following?

14. On your mother's side, is there a history of any of the following?

Cardiac conditions, heart disease, early stroke, clotting conditions, sudden death, blood disorders (sickle cell anemia, thalassemia) or hemophilia. Also, kidney conditions/defects, cystic fibrosis, celiac disease, limb abnormalities, or cleft lip/ cleft palate.  Who is affected?

15.  On your father's side, is there a history of any of the following?

15. On your father's side, is there a history of any of the following?

Cardiac conditions, heart disease, early stroke, clotting conditions, sudden death, blood disorders (sickle cell anemia, thalassemia) or hemophilia. Also, kidney conditions/defects, cystic fibrosis, celiac disease, limb abnormalities, or cleft lip/ cleft palate.   Who is affected?

16.  Does your partner/spouse have a family history of the following?

16. Does your partner/spouse have a family history of the following?

As listed above.   Who is affected?

17.  On your mother's side, is there a history of any of the following?

17. On your mother's side, is there a history of any of the following?

Multiple miscarriages, stillbirth, neonatal deaths, infertility, Alzheimer disease, mental illness.  Also, chronic conditions (diabetes), genital abnormalities or report of any other unusual features/birth defects. Who is affected?

18.  On your father's side, is there a history of any of the following?

18. On your father's side, is there a history of any of the following?

Multiple miscarriages, stillbirth, neonatal deaths, infertility, Alzheimer disease, mental illness. Also, chronic conditions (diabetes), genital abnormalities or report of any other unusual features/birth defects. Who is affected?

19.  Does your partner/spouse have a family history of the following?

19. Does your partner/spouse have a family history of the following?

As listed above. Who is affected?

20.  Describe Hospitalization and Surgical History

20. Describe Hospitalization and Surgical History

(pertains to person completing this form) 

21.  List current medications and prescriptions

21. List current medications and prescriptions


22.  Verifier

22. Verifier

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