Family Health History Questionnaire Template

Thank you for taking the time to share your family's health information with us. This questionnaire will help us better understand your family's medical history and any potential health risks that may be passed down through generations. Your responses will be kept confidential. and will only be used to provide you with the most appropriate care. 
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1.

Bisic Information

Name
Name
Date of Birth
Date of Birth
Gender
Gender
*
2.

Contact Information

Email
Email
Phone number
Phone number
*
3.
Have you ever been diagnosed with any of the following illnesses?
[Checkboxes]
High blood pressure
Diabetes
Heart disease
Lung disease
Kidney disease
Liver disease
Stroke
Cancer
None of the above
4.
Have any of your relatives been afflicted with any of the following illnesses?
[Checkboxes]
ParentsGrandparentsSibling
High blood pressure
Diabetes
Heart disease
Lung disease
Kidney disease
Liver disease
Stroke
Cancer
5.
Is there anything else you would like to share about your medical history or current health status?
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