Confidential Family Health History Form

Confidential Family Health History Form
This form is designed to facilitate sharing of private health information between family members and their care providers.
For parents or other family members to complete and share with their adult children.

Your name _________________________________ Your Date of birth____________________________

Your Parent's Name___________________ Current Age or Cause of Death__________________________

Your Grandparent's Name___________________ Current Age or Cause of Death_____________________

Family Medical History - include siblings, children, grandparents, parents, aunts, uncles, cousins, etc.

Disease	Family Members' Names and/or Relationship to Child	Age of First Occurrence/type
Allergies (both drug and environmental)
Alzheimer's Disease
Anxiety
Arthritis
Asthma
Blood disorder
Cancer
Cholesterol problems (high LDL or triglycerides, low HDL, etc)
Diabetes or other sugar-related disorder
Depression
Epilepsy or other seizure disorder
Eye conditions
Hearing problems
Heart disease
High blood pressure
Kidney disease
Liver disease
Lung disease
Obesity
Osteoporosis
Parkinson's Disease
Psychiatric disorder
Sexual or reproductive disorder (male or female)
Sexually transmitted disease/HIV
Sinus problems
Smoking
Stroke
Substance abuse
Suicide
Thyroid problems
Tuberculosis
Ulcer
Other (specify)

Part II is intended for a parent to complete for each adult child individually,
for the information of that son or daughter and his/her healthcare providers.

Child's Name: ____________________ Child's Date of Birth: ________________________________ Child's Birth Order: ______ of ______

Was the above named child was born:	[ ] Full-term Early [ ] Post-term [ ] Early
If the child was born early, how many weeks early he/she was born.	.
If there were any problems during your pregnancy, please describe.	.
If there were any problems after the birth, please describe.	.
If the child had any later medical problems/illnesses, please describe.	.
Did anyone in the home smoke tobacco during the pregnancy with this child?	[ ] Frequently [ ] Rarely [ ] Not at all \| Remarks:
Did the mother drink alcohol during her pregnancy with this child?	[ ] Frequently [ ] Rarely [ ] Not at all \| Remarks:
Did anyone in the home abuse drugs during the pregnancy with this child?	[ ] Frequently [ ] Rarely [ ] Not at all \| Remarks:
At what age did this child first walk? Were any problems observed?	.
At what age did this child first talk? Were any problems observed?	.
What 'childhood illnesses' did this child experience (mumps, chicken pox, measles, etc.) and at what age?	.
During this child's early growth, did you develop concerns about his/her health (hearing, vision, speech, emotional development, etc.) If so, please describe.	.

This form may either be printed out and handwritten, or copy-and-pasted into an e-mail or word-processing application for typing and e-mailing.