My Family Health Portrait
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1
2Family Information
t
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f
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a
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amily
elatioNship
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liviNg
ge
r
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(
/
)
h
(B
)
elative
s Name
(
/
)
to you
y
N
ealth coNDitioN
DiagNosis
at Death
List below your blood relatives and the illnesses they may have suffered, even if you do not know the medical
lood related only
y
N
p
i
ersoNal
NformatioN
name. Refer back to the box, “Number of Family Members” so you don’t forget anyone. Fill in as much
m
’
other
s
information as you can. Be sure to report diseases such as heart disease, stroke, diabetes, or cancer (especially
coNtiNueD
colon, breast, or ovarian cancers) that have occurred in your family.
Name:
(Last)______________________________________
t
?
f
r
a
?
a
wiN
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ge
amily
r
’
elatioNship
liviNg
elative
s Name
(
/
)
h
(
/
)
(B
)
y
N
ealth coNDitioN
DiagNosis
at Death
(First)_____________________________________
lood related only
to you
y
N
Date of Birth _________________
i
mmeDiate
(brothers,
sisters,
Are you an identical twin?
Yes___ No___
parents,
children)
Record the number of family members
Record whether you have any of the 6 conditions listed
you have in the box below. These are the
below. These diseases are tracked because they are
family members who are most relevant to
common and we have very good information about how to
your health history.
avoid them.
In the spaces labeled “Other,” enter other diseases or
f
’
ather
s
conditions you have.
(his father,
his mother,
Once you complete this tool, you can enter the information
his sisters,
online at
his brothers)
D
a
o
you have aNy
ge at
N
Y
/
?
es
nO
umber of family members
D
of
these
health coNDitioNs
iagNosis
Related by blood, living or deceased
h
eart disease
4
G
: _________
s
randparents
trOke
1
M
:
_________
Other
d
iaBetes
1
F
:
_________
ather
c
a
:
_________
OlOn cancer
unts
m
’
other
s
u
:
_________
ncles
B
reast cancer
(her father,
s
:
_________
isters
O
varian cancer
her mother,
B
:
_________
rOthers
her sisters,
d
:
_________
auGhters
her brothers)
s
:
_________
Ons
h
:
_________
alF sisters
h
: _________
alF BrOthers
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