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Questionnaire template

Family Health History

Collects a patient's close-family history of major conditions, onset, lifestyle and prevention to assess inherited risk.

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Questions in this template

Your Family's Health

  1. Thank you for completing this form. Knowing your family's health history helps us judge your own risks and tailor our advice. Questions about family refer to your parents, brothers, sisters and children.

  2. Has any close family member been diagnosed with a long-term illness?

    Choose one:

    • Yes
    • No
    • Not sure

  3. Which illness was it, and which family member was affected?

    Condition: Shown when a long-term illness was reported

    Open answer

Specific Conditions

  1. Has any close family member had each of these conditions?

    • Heart disease
    • Cancer
    • Diabetes
    • Stroke
    • Mental illness

    For each row: choose one:

    • Yes
    • Not sure
    • No

  2. Did the family members who had these conditions receive treatment?

    Condition: Shown when at least one condition was reported

    Choose one:

    • Yes, all of them
    • Some of them
    • No
    • Don't know

Onset and Severity

Condition: Only when at least one condition was reported

  1. Overall, how serious were these conditions for the family members affected?

    Choose one:

    • 1 - Very mild
    • 2
    • 3
    • 4
    • 5 - Very severe

  2. Was any of these conditions diagnosed before the family member turned 50?

    Choose one:

    • Yes
    • No
    • Not sure

Lifestyle

  1. Which of these were common in the household you grew up in? Select all that apply.

    Choose any that apply:

    • Smoking
    • Heavy drinking
    • Little physical activity
    • A diet high in processed food
    • None of these

  2. Which best describes your own smoking?

    Choose one:

    • I have never smoked
    • I used to smoke
    • I smoke now

Your Own Prevention

  1. Which of these do you currently do to protect your health? Select all that apply.

    Choose any that apply:

    • Regular exercise
    • A healthy diet
    • Regular check-ups or screening
    • Taking prescribed medicines
    • None of these

  2. Is there anything else about your own or your family's health that would be useful for us to know?

    Open answer