Please describe the drug and alcohol use of your family. Family History Questionnaire Page 1 of 9 FAMILY HISTORY QUESTIONNAIRE Completing this questionnaire will help us to determine the risk of a hereditary cancer predisposition in your family. Family History Form Date _____ Please complete as much of this form as possible and RETURN it before your next appointment. NGS offers two versions of a Pedigree Chart (sometimes called an Ancestor Chart) and one version of the Family Group Sheet. When? This information may be useful to your doctor prior to your appointment. Learning to use a Pedigree Chart and a Family Group Sheet is one of the first steps in collecting and organizing your family history. (Index)Patient _____ Date _____ Please complete as much of this form as possible and RETURN it before your next appointment. For your children, please write in the name of child at top of each column. 4 | P a g e Family Medical History – Do any family members have a personal history of any of the following? CHILD & FAMILY HISTORY FORM Dr. Victoria Fitzgerald, PLLC 7 Has your child ever had Speech Therapy? Chippewa Valley Northland Oakridge What name do you like to be called?_____ HEALTH HISTORY (continued) THESE QUESTIONS ARE ABOUT YOUR PERSONAL AND YOUR FAMILY MEDICAL HISTORY: Please indicate if you or any members of your immediate family have had any of the following: Illness You Mother Father Siblings (indicate brother or sister) Provider Notes DIABETES (sugar) Yes / No Yes / No Yes / No Yes / No HEART DISEASE Family History Form Rev 10/17 Page 3 of 3 DRUG AND ALCOHOL USE A. Where? Blake Psychology: Pointe-Claire 6500 Trans-Canada Hwy, Suite 400 Pointe-Claire, QC H9R 0A5 www.blakepsychology.com T: 514-319-1744 F: 1-877-417-4420 All of our free charts here are “fillable.” That means you can. Texas A&M AgriLife Extension Service Page 1 A Family History Questionnaire A Family History Questionnaire by Virginia Allee Introduction The purpose of this questionnaire is to provide you with a mind jogger to help you in making notes on your own life or to guide you in recording the life experiences of another member of your family. How Often? If so, what? _____ _____ FAMILY Is there a pattern of physical illness in your family, which keeps repeating (e.g., heart disease, cancer, seizures, etc.)? Additiona lly, this form may be viewed on-site by an employee or designee of the OHP as part of a quality assuranc e audit to ensure the clinic’s compliance with OHP’s clinical practice guidelines. Please answer these questions as completely as possible. (Check ALL that apply) Problem Mo Fa Bro Sis MGMo MGFa PGMo PGFa Son Dau Alcohol/Drug Abuse Allergies Adult Family History Form . If you are agreeable to providing your family history … Martin Family Medicine-Robersonville232 501 N. Main Street Robersonville, NC 27871 Phone: 252-284-3501 OPENING NOV. 2, 2020 To Schedule appointment go to Website: martingeneralanytime.com revised 08/01/2020 Martin FamilyMedicine GreenStreet Williamston, NC 27892 Phone: 252-809-6400 PATIENT INTAKE AND HISTORY FORM download the PDF, History Form – Primary Care Location: Eau Claire . with the best possible care. Use the number which best describes how often each person uses each drug. Relationship Chart – This chart shows how each member of a family tree is related to another. Have their ever been any concerns about his/her development? This information may be useful to your doctor prior to your appointment. Family Group Sheet – This is a family chart that shows the parents and children in one family with details about the names, dates, and places of births, marriages, and deaths(if applicable) of the individuals in question. If you are uncertain about any information, please write in your best guess or write unknown.