Family Health History Patient name: First Last Today's date: MM slash DD slash YYYY Indicate if: Parents adopted child Child in foster care Other: None of the above apply: Check if none apply Father: Anesthesia problems Clotting disorders Heart disease Kidney cancer Sickle cell trait Cancer Urinary problems High blood pressure Prostate cancer Malignant hyperthermia Kidney stones Other: Mother: Anesthesia problems Clotting disorders Heart disease Kidney cancer Sickle cell trait Cancer Urinary problems High blood pressure Prostate cancer Malignant hyperthermia Kidney stones Other: Paternal grandfather: Anesthesia problems Clotting disorders Heart disease Kidney cancer Sickle cell trait Cancer Urinary problems High blood pressure Prostate cancer Malignant hyperthermia Kidney stones Other: Paternal grandmother: Anesthesia problems Clotting disorders Heart disease Kidney cancer Sickle cell trait Cancer Urinary problems High blood pressure Prostate cancer Malignant hyperthermia Kidney stones Other: Maternal grandfather: Anesthesia problems Clotting disorders Heart disease Kidney cancer Sickle cell trait Cancer Urinary problems High blood pressure Prostate cancer Malignant hyperthermia Kidney stones Other: Maternal grandmother: Anesthesia problems Clotting disorders Heart disease Kidney cancer Sickle cell trait Cancer Urinary problems High blood pressure Prostate cancer Malignant hyperthermia Kidney stones Other: Sibling(s): Anesthesia problems Clotting disorders Heart disease Kidney cancer Sickle cell trait Cancer Urinary problems High blood pressure Prostate cancer Malignant hyperthermia Kidney stones Other: PhoneThis field is for validation purposes and should be left unchanged. Δ
