Name _________________________ Section ________________ Date ___________________
W E L L N E S S WO R K S H E E T 4 5
Creating a Detailed Family Health History and Tree
Knowing that a specific disease runs in your family allows you to watch closely for the early warning signs
and get appropriate screening tests. It can also help you target important health habits to adopt. As described
in Wellness Worksheet 8, you can put together a simple family health tree by compiling key facts on your primary relatives: siblings, parents, aunts and uncles, and grandparents. If possible, have your primary relatives
fill out a family health history record like the one below.
Family Health History Form
Name: ________________________________
Ethnicity: ____________
Date of birth: ______________
Blood and Rh type: ______________________
Occupation: ______________________________________
Please note any serious or chronic diseases you have experienced, with special attention to the following:
______ Alcoholism
______ Allergies
______ Arthritis
______ Asthma
______ Blood diseases (hemophilia, sickle-cell
disease, thalassemia, hemochromatosis)
______ Cancer (breast, bowel, colon,
ovarian, skin, stomach, etc.)
______ Cystic fibrosis
______ Diabetes
______ Epilepsy
______ Mental retardation (Down syndrome,
fragile X syndrome, etc.)
______ Migraine headaches
______ Miscarriages or neonatal deaths
______ Multiple sclerosis
______ Muscular dystrophy
______ Myasthenia gravis
______ Obesity
______ Phenylketonuria (PKU)
______ Recurrent or severe infections
______ Hearing impairment
______ Respiratory disease (emphysema,
chronic bronchitis)
______ Heart defects or disease
______ Rh disease
______ High blood cholesterol levels
______ Skin disorders
______ Huntington’s disease
______ Tay-Sachs disease
______ Hypertension (high blood pressure)
______ Thyroid disorders
______ Learning disabilities (dyslexia, attentiondeficit/hyperactivity disorder, autism)
______ Tuberculosis
______ Liver disease
______ Visual disorders (dyslexia, glaucoma,
retinitis pigmentosa)
______ Lupus
______ Other (please list):
______ Mental illness (bipolar disorder,
schizophrenia)
(over)
Insel/Roth, Connect Core Concepts in Health, Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter 8
Insel/Roth, Connect Core Concepts in Health, Brief Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter 5
WELLNESS WORKSHEET 45 — continued
List any of your lifestyle behaviors that may have health-related consequences (including tobacco use, dietary
and exercise habits, and alcohol use):
Please note names of your relatives below, along with indications of any illnesses, such as those listed on the
previous page, that affected them. If they are deceased, list age and cause. Also make note of their lifestyle
habits such as smoking.
Father: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Mother:__________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Brothers and sisters:________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Children of brothers and sisters: ______________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
If you don’t have enough information on past generations, you can get clues by requesting death certificates
from state health departments or medical records from relatives’ physicians or hospitals where they died. Once
you’ve collected the information you want, plug it into a tree format. (An online version of a family health
tree is available at http://familyhistory.hhs.gov.)
SOURCE: Adapted from March of Dimes Birth Defects Foundation. 2001. Genetic Counseling. Copyright © March of Dimes
Birth Defects Foundation, 2001. Reprinted with permission.
Name _________________________ Section ________________ Date ___________________
W E L L N E S S WO R K S H E E T 8
Create a Family Health Portrait
The Surgeon General’s Family History Initiative encourages all American families to learn more about their
family history. Knowing your family health history is a powerful guide to understanding risk for disease.
However, keep in mind that a family history of a particular illness may increase risk, but it almost never
guarantees that other family members will develop the illness.
To get the most accurate health history information, it is important to talk directly with your relatives. Explain
to them that their health information can help improve prevention and screening of diseases for all family
members.
Start by asking your relatives about any health conditions they have had—including history of chronic illnesses, such as heart disease; pregnancy complications, such as miscarriage; and any developmental disabilities. (You may want to refer to Wellness Worksheet 45 for a list of conditions and diseases.) Get as much
specific information as possible. It is most useful if you can list the formal name of any medical condition that
has affected you or your relatives. You can get help finding information about health conditions that have
affected you and your family members—living or deceased—by asking relatives or health care professionals
for information or by getting copies of medical records. If you are planning to have children, you and your
partner should each create a family health portrait and show it to your health care professional.
The Family Health Portrait chart on the following pages will help you collect and organize your family information. (You can also complete a family health history at http://familyhistory.hss.gov.) No form can reflect
every version of the American family, so use this chart as a starting point and adapt it to your family’s needs.
First, complete the personal information, including the number of relatives you have in each category and
whether you have any of the six conditions listed. Then complete the family information, including any health
conditions your family members have, their age at diagnosis, and, if they are deceased, the age at which they
died. Because some conditions are more common in people with certain ethnic ancestries, you may also want
to record your relatives’ ancestry or country of origin under their names.
Once you complete the Family Health Portrait, take it to your health care professional so that he or she can
better individualize your health care. Be sure to make a copy for your records and update it as circumstances
change or you learn more about your family’s health history.
(over)
Insel/Roth, Connect Core Concepts in Health, Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter 1
Insel/Roth, Connect Core Concepts in Health, Brief Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter 1
WELLNESS WORKSHEET 8 — continued
PERSONAL INFORMATION
Name:
(Last)______________________________________
(First)_____________________________________
Date of Birth _________________
Are you an identical twin?
Record the number of family members
you have in the box below. These are the
family members who are most relevant to
your health history.
Yes___ No___
Record whether you have any of the 6 conditions listed
below. These diseases are tracked because they are
common and we have very good information about how to
avoid them.
In the spaces labeled “Other,” enter other diseases or
conditions you have.
DO YOU HAVE ANY
OF THESE HEALTH CONDITIONS?
NUMBER OF FAMILY MEMBERS
Related by blood, living or deceased
YES/NO
AGE AT
DIAGNOSIS
HEART DISEASE
STROKE
DIABETES
COLON CANCER
BREAST CANCER
OVARIAN CANCER
OTHER
4
GRANDPARENTS: _________
1
_________
MOTHER:
1
FATHER:
_________
AUNTS:
_________
_________
UNCLES:
SISTERS:
_________
_________
BROTHERS:
DAUGHTERS:
_________
SONS:
_________
_________
HALF SISTERS:
HALF BROTHERS: _________
(over)
WELLNESS WORKSHEET 8 — continued
Family Information
List below your blood relatives and the illnesses they may have suffered, even if you do not know the medical
name. Refer back to the box, “Number of Family Members” so you don’t forget anyone. Fill in as much
information as you can. Be sure to report diseases such as heart disease, stroke, diabetes, or cancer (especially
colon, breast, or ovarian cancers) that have occurred in your family.
FAMILY
(BLOOD RELATED ONLY)
RELATIVE’S NAME
RELATIONSHIP
TO YOU
TWIN?
(Y/N)
HEALTH CONDITION
AGE AT
DIAGNOSIS
LIVING?
(Y/N)
AGE
AT DEATH
IMMEDIATE
(brothers,
sisters,
parents,
children)
MOTHER’S
(her father,
her mother,
her sisters,
her brothers)
(over)
Insel/Roth, Connect Core Concepts in Health, Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter 1
Insel/Roth, Connect Core Concepts in Health, Brief Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter 1
WELLNESS WORKSHEET 8 — continued
FAMILY
(BLOOD RELATED ONLY)
RELATIVE’S NAME
RELATIONSHIP
TO YOU
TWIN?
(Y/N)
HEALTH CONDITION
AGE AT
DIAGNOSIS
LIVING?
(Y/N)
AGE
AT DEATH
MOTHER’S
CONTINUED
FATHER’S
(his father,
his mother,
his sisters,
his brothers)
SOURCE: Department of Health and Human Services. 2007. The Surgeon General’s Family History Initiative: My Family
Health Portrait (http://www.hhs.gov/familyhistory; retrieved November 19, 2008).
Family Health Tree and Paper
Due May 3rd
All guidelines and specifics can be found in the syllabus
Family Information Collection
The website below can help you organize your family health
information. Also it can assist in the creation of your family tree.
• https://familyhistory.hhs.gov/FHH/html/index.html
Family Health Tree Examples
APA Style Aides
•Easybib.com
•Bibme.org
•Apastyle.org
•Smith Vidal Literacy and Language
Center
MLK Building, Room 204
301-860-3720
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