Family Medical History Questionnaire Page 3
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5ALL
ABOUT
YOUR
SIBLINGS
Fill
out
the
forms
below
with
your
siblings’
information
(living
and
deceased).
Name:
Name:
Name:
Relationship:
Relationship:
Relationship:
Date
of
birth:
Date
of
birth:
Date
of
birth:
Known
health
problems:
Onset
Known
health
problems:
Onset
Known
health
problems:
Onset
age:
age:
age:
❑
❑
❑
Alcohol
and/or
drug
abuse
Alcohol
and/or
drug
abuse
Alcohol
and/or
drug
abuse
❑
❑
❑
Allergies
Allergies
Allergies
❑
Asthma
❑
Asthma
❑
Asthma
❑
❑
❑
Cancer
Cancer
Cancer
❑
Depression
❑
Depression
❑
Depression
❑
❑
❑
Diabetes
Diabetes
Diabetes
❑
❑
❑
Heart
disease
Heart
disease
Heart
disease
❑
High
blood
pressure
❑
High
blood
pressure
❑
High
blood
pressure
❑
❑
❑
High
cholesterol
High
cholesterol
High
cholesterol
❑
Mental
Illness
❑
Mental
Illness
❑
Mental
Illness
❑
❑
❑
Stroke
Stroke
Stroke
❑
❑
❑
Other
________________________
Other
________________________
Other
________________________
❑
❑
❑
Other
________________________
Other
________________________
Other
________________________
❑
❑
❑
Other
________________________
Other
________________________
Other
________________________
❑
❑
❑
❑
❑
❑
Does
he
or
she
smoke?
Yes
No
Does
he
or
she
smoke?
Yes
No
Does
he
or
she
smoke?
Yes
No
Is
he
or
she
deceased?
❑
Yes
❑
No
Is
he
or
she
deceased?
❑
Yes
❑
No
Is
he
or
she
deceased?
❑
Yes
❑
No
If
yes,
at
what
age?
______________________
If
yes,
at
what
age?
______________________
If
yes,
at
what
age?
______________________
If
yes,
of
what
cause?
______________________
If
yes,
of
what
cause?
______________________
If
yes,
of
what
cause?
______________________
List
any
questions
or
concerns
you
may
List
any
questions
or
concerns
you
may
List
any
questions
or
concerns
you
may
have
about
their
medical
history:
have
about
their
medical
history:
have
about
their
medical
history:
For
more
health
and
wellness
information,
visit
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Parent category: Life