my family health history - national heart, lung, and blood institute · 2015-07-01 · y family...

My Family Health History 1 Fill in the blanks below for each of your immediate family members. Looking at their health history can give you information about your own health and habits. Think of health conditions such as high blood pressure, high blood cholesterol, diabetes, overweight, heart attack, and stroke that affect your family members. Maternal (from your mom’s side) Grandmother Grandfather Mother Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Paternal (from your dad’s side) Grandmother Grandfather Father Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Name:_______________________ Age: ________________________ Health conditions: ______________ ____________________________ ____________________________ Has this person passed away?: Yes No If yes, at what age?______________ How? _______________________ Name:_______________________ Age: ________________________ Health conditions: _____________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ You Sibling Sibling

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My Family Health History

Fill in the blanks below for each of your immediate family members. Looking at their health history can give you information about your own health and habits. Think of health conditions such as high blood pressure, high blood cholesterol, diabetes, overweight, heart attack, and stroke that affect your family members.

Maternal (from your mom’s side)Grandmother Grandfather

Mother