Family Medical History Questionnaire
Family medical history questionnaire is an effective evaluation made by several health experts to identify the disease risk for an individual. This in turn helps the physician to diagnose a patient suffering from hereditary diseases. Even the prevention program from certain disease could also be achieved through this questionnaire.
Sample Family Medical History Questionnaire
Name of the patient: ____________________________________________ Sex: ______
Age: ________ Date of Examination: _____________
Since it is the family medical history and it will be used for evaluating your health, so should answer it with accuracy and completely. All the information provided will be kept confidential.
1) Please list the medical problems you have presently:
Medical Problems Date of onset Comments
______________ ________________ _____________________
______________ ________________ _____________________
______________ _________________ ______________________
2) How many siblings you have? Do they have any of these problems?
3) Does any of your parents ever diagnosed with such complications? Mention with details.
________________________________________________________________________
4) Do any of your parents have complications related to blood sugar, cholesterol and blood pressure?
5) Do any of your family members are suffering from heart diseases or any other complications?
________________________________________________________________________
6) Do you have undergone any surgery at past? Please mention.
7) Do any of your parents or family members have complications like migraine, asthma, sinus or any other?
Do any of your ancestors have persisting problem of any kind of allergy?
9) Do any of your parents or siblings have skin problems like Psoriasis, Poison Ivy, Primordial Cyst or any other?
__________________________________________________________________
10) Please mention if your parents had any surgical related complications?
________________________________________________________________________
Category: Medical Questionnaire