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Family Medical History Form Template

Streamline Your Family's Health Insights

Keeping track of your family's medical history can be overwhelming, especially when trying to gather information for doctor visits. This Family Medical History Form Template helps you collect essential details that can lead to better healthcare decisions for you and your family. Whether you need to assess hereditary risks, prepare for appointments, or simply maintain a comprehensive health record, this template makes the process easy and efficient. Enjoy features like customizable sections, easy-to-read formatting, and the ability to share with healthcare professionals. Start using the template today to ensure your family's health history is complete.

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Patient full name
Date of birth
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If you prefer to self-describe, please specify
Email address
Phone number
Sex assigned at birth
Female
Male
Intersex
Unknown
Prefer not to say
Are you completing this form for yourself?
Yes
No
Your full name (if different from patient)
Your relationship to the patient
Self
Parent
Legal guardian
Spouse/Partner
Adult child
Sibling
Prefer not to say
Other
Please Specify:
Were you adopted?
Yes
No
Unknown
Prefer not to say
Are the patient's parents related by blood (consanguinity)?
Yes
No
Unknown
Prefer not to say
Ancestry or heritage groups that apply
Please Specify:
Please list the relative(s), condition(s), and age at diagnosis for any conditions selected (include maternal or paternal side if known)
Which blood relatives have had any of the following conditions?
Please Specify:
Immediate family details (ages or age at death, notable conditions)
Anything else you would like the clinician to know
I certify the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Signature (type full name)
Date signed
I consent to the use of this information for my medical care.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
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Paper art illustration depicting a Family Medical History Form Template for FormCreatorAI article

When to use this form

Use this form when you need a clear picture of inherited risks before a visit. It fits new patient intake, pre-op checks, fertility planning, and cancer or cardiometabolic screening. Clinicians, genetic counselors, and telehealth teams benefit from structured answers that guide testing and prevention. Add it to onboarding with the New patient registration form to reduce repeat questions. Pair it with a Health questionnaire form to capture lifestyle data that shapes risk, and use the HPI Form to focus the visit on current symptoms. Patients get a simple checklist; you get reliable data you can act on.

Must Ask Family Medical History Questions

  1. Which blood relatives have had cancer, and at what ages?

    These details help estimate hereditary cancer risk and set screening or genetic counseling plans. Recording the type and age at diagnosis clarifies early-onset patterns that change follow-up.

  2. Do your parents, siblings, or grandparents have heart disease, stroke, high blood pressure, or high cholesterol?

    Cardiovascular problems often run in families, so documenting them supports risk scores and prevention choices. It can guide labs, imaging, and lifestyle goals during intake.

  3. Is there a family history of diabetes, kidney disease, or thyroid disorders?

    Endocrine and kidney disorders have genetic links; flagging them prompts earlier testing and monitoring. This informs A1C, thyroid panels, and renal screening schedules.

  4. Has anyone in your family had depression, anxiety, bipolar disorder, or substance use disorder?

    Mental health history highlights inherited risk and safety needs. If you plan a deeper screen, use the Patient health questionnaire form to standardize severity.

  5. Has any relative had an early or sudden death, or a known genetic condition (for example, sickle cell or cystic fibrosis)?

    Early or sudden deaths and named genetic conditions point to the need for genetics referral and family cascade testing. This also guides carrier screening and preconception counseling.

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