Family History Questionnaire

(Example: genetic counseling for test report, genetic counseling to learn about available tests for adult neurology diagnosis, genetic counseling for cancer risk assessment, etc.)

Enter question here. Additional concerns may not be addressed in the current session, based on laboratory and referral arrangements.

Third item of concern. Additional concerns may not be addressed in the current session, based on laboratory and referral arrangements.

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

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

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?

As listed above. Who is affected?

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?

As listed above. Who is affected?

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?

As listed above. Who is affected?

(pertains to patient)

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1. Today’s Date

2. Your Name

3. Age

4. Address

5. What is your main question for the Genetic Counselor

6. What else do you have questions about?

7. What else do you have questions about?

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

9. Are you adopted?

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

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

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

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

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

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

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

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

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

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

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

21. Describe Hospitalization and Surgical History

22. List current medications and prescriptions

23. Verifier

24. Text