Family Medical History Form

The Family Medical History Form provides a structured approach to documenting hereditary disease risk across multiple generations. It covers first-degree relatives (parents, siblings, children) and second-degree relatives (grandparents, aunts, uncles) with specific attention to conditions with known genetic components: cancer (by type and age of onset), cardiovascular disease, diabetes, neurological conditions, autoimmune disorders, and mental health conditions.

The form is organized by condition category rather than by relative, making it efficient for patients to complete. For each positive family history, patients indicate which relative was affected, age of onset, and outcome. This structured format makes it easy for providers to assess cumulative risk and determine appropriate screening recommendations.

This template is valuable for primary care, genetics counseling, oncology risk assessment, and preventive health programs. It helps identify patients who may benefit from enhanced screening protocols (e.g., early colonoscopy for family colon cancer history) or genetic testing referrals. The form can be updated periodically as family health information changes.