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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