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FAMILY HISTORY Patient’s Name_____________________________ Date of Birth__________________________ Completed by____________________________ Relation_______________ Today’s Date__________ If condition is present in the family, check the box and list to the right of the box, the relative’s relationship to child as: Mother (M), Father (F), child’s Brother (B), or Sister(S), Maternal Aunt/Mom’s sister (M Aunt), Paternal Aunt/Dad’s sister (P Aunt), Maternal Grandmother/Mom’s mother (MGM), Paternal Grandmother/Dad’s Mother (PGM), Maternal Grandfather/Mom’s father (MGF), paternal uncle/Dad’s brother (P Uncle), etc. Only list family related by blood. List here names of siblings with the SAME family history:_______________________________________________ If unknown, mark here: maternal family history unknown if Yes check and list Who? Allergies to_______________ _____________ Drug Allergy to ______________ Alcohol problem Asthma ________________ Drug Problem ______________ ____________________________ _____________________ ADD or ADHD paternal family history unknown if Yes check Hepatitis B _________ Heart disease (specify) ____________ ___________ Heart attack (age at heart attack ____) High Blood Pressure _________ High Cholesterol Hip dysplasia (congenital/developmental) __________________ Kidney Disease (specify) Autism/Aspergers __________________ Learning disability _____________ __________________ or C Anorexia/Bulimia Birth Defect specify:___________ and list Who? ______ _____________ Kidney stone __________ __________________________ ____________ Mental Retardation/Cognitive Impairment Blood Disorder (specify) ____________________ Factor V Leiden Deficiency ________________ Hemophilia ____________________________ Von Willebrand’s _______________________ Mental Health Condition _____________________ Anxiety ____________ Other ____________ Bipolar ____________ Schizophrenia _______ Depression __________ Suicide ___________ Cancer (what kind?_____________) Migraine Headaches Crohn’s Disease _______________ Ulcerative Colitis __________ ________________________ Cystic Fibrosis Rheumatoid Arthritis Scoliosis Lupus cause?_______ who?_________ Seizure Disorder Diabetes: Type 1 Type 2 Sickle Cell Disease Eczema ___________________________ Eye/vision problem specify___________ _________ other ____________________________ Trait Stroke (age at stroke ____) Thyroid disease ______________ _____________________________ Death before age 70 _______________ ___________________ hyper ________________ ____________ hypo __________ If the answer to all of the above is NO check here List other conditions not noted above or details: __________________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ FAMILY HISTORY Patient’s Name_____________________________ Date of Birth__________________________ Completed by____________________________ Relation_______________ Today’s Date__________ If condition is present in the family, check the box and list to the right of the box, the relative’s relationship to child as: Mother (M), Father (F), child’s Brother (B), or Sister(S), Maternal Aunt/Mom’s sister (M Aunt), Paternal Aunt/Dad’s sister (P Aunt), Maternal Grandmother/Mom’s mother (MGM), Paternal Grandmother/Dad’s Mother (PGM), Maternal Grandfather/Mom’s father (MGF), paternal uncle/Dad’s brother (P Uncle), etc. Only list family related by blood. List here names of siblings with the SAME family history:_______________________________________________ If unknown, mark here: maternal family history unknown if Yes check and list Who? Allergies to_______________ Hemochromatosis _____________ ___________________ paternal family history unknown if Yes check Hepatitis B Tuberculosis or C and list Who? __________________ Immune disorder HIV/AIDS If the answer to all of the above is NO check here List other conditions not noted above or details: ____________________________________________________________________ _______
