Family Medical History Questionnaire printable pdf download

Your Family Medical History Questionnaire 

Even if you’re healthy now, knowing your family health history will 

provide important clues to your future health and the future 

health of your family. Do certain diseases and health conditions 

run in your family? If you’re unsure, begin collecting your family 

health history today by using this easy to follow questionnaire and checklist.  

You may feel uncomfortable asking for personal health information from some family members, but it’s 

important to try. Pick a time when you’re less likely to get interrupted so your discussion can be more 

relaxed. And, remember, older relatives (and even younger relatives) may not use the same health 

terms as you do, so be aware to listen for clues about how they might describe a relative’s behavior or 

health history. For example, “Grandmother always spent about a week in bed in the dark each month,” 

could indicate that she suffered from menstrual migraines.  

The information you gather will help you and your health care provider determine what health problems 

you may be at increased risk for in the future so that you can take action today to lower those risks. At 

HealthyWomen, we want you to live the longest, healthiest life possible. This Family Medical History 

Questionnaire can help you do just that. 

ALL ABOUT YOU 

Your name: 

List any questions or concerns you may have 

Date of birth: 

about your medical history: 

Blood type: 

Ethnic origin: 

Known health problems: 

Onset 

age: 

❑

Alcohol and/or drug abuse  

❑

Allergies 

❑

Asthma 

List any lifestyle or environmental factors 

❑

Cancer If yes, what kind?  ___________________ 

related to your health and wellness: 

❑

Depression 

❑

Diabetes 

❑

Heart disease 

❑

High blood pressure 

❑

High cholesterol 

❑

Mental Illness 

❑

Stroke 

❑

Other  _________________________________________ 

❑

Other  _________________________________________ 

Do you take risks with your health, such as, 

Do you smoke?  

❑

Yes    

❑

abuse drugs and alcohol, drive over the speed 

If yes, cigarettes smoked per day:        _______________________ 

limit, not wear a seat belt or have multiple 

If yes, totals years as a smoker:             _______________________ 

sexual partners or unprotected sex? 

❑

Yes    

No      If yes, please describe:  

How often do you experience stress:  _______________________ 

❑

Do you get regular physical activity?  

Yes    

If yes, how often?  _____________________________________________ 

Is your diet healthy and balanced?      

❑

Yes    

❑

For more health and wellness information, visit 

Family Medical History Questionnaire

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