Family History Questionnaire

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Family History Questionnaire
Please complete the chart below. Provide as much information as you are able, and use
the back or attach additional sheets as needed. Do not include information about family
members who are not biologically related to you.
Mother’s Side of Family (Biological)
Father’s Side of Family (Biological)
If
If
1) Cause of death
1) Cause of death
If in
If in
Living
Living
Relationship
2) Age at death
Relationship
2) Age at death
Good
Good
Current
Current
3) Health problems
3) Health Problems
Health
Health
Age
Age
Grandmother
Grandmother
Grandfather
Grandfather
Aunt(s)
Aunt(s)
Uncle(s)
Uncle(s)
Biological Mother
Biological Father
Name and
Name and
1) Cause of death
1) Cause of death
If in
If in
If
If
current age
current age
2) Age at death
2) Age at death
Good
Good
Living
3) Health problems
Living
3) Health problems
if living
if living
Health
Health
Your Sisters
Your Brothers
Name and
Name and
1) Cause of death
1)Cause of death
If in
If in
If
If
current age
current age
2) Age at death
2) Age at death
Good
Good
Living
3) Health problems
Living
if living
if living
3) Health problems
Health
Health
Your Daughters
Your Sons
Name and
Name and
1) Cause of death
1) Cause of death
If in
If in
If
If
current age
current age
2) Age at death
2) Age at death
Good
Good
Living
3) Health problems
Living
if living
if living
3) Health problems
Health
Health

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