Family Medical History
Cancer
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Score 0 if none, otherwise 1 for each disease or disorder noted, and for each relative category |
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Siblings |
Parents |
Cousins |
Uncle/Aunts |
Grandparents |
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Cancer |
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Bladder cancer |
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Colorectal cancer |
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Kidney cancer |
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Liver cancer |
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Melanoma |
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Ovarian cancer |
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Prostate cancer |
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Breast cancer |
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Endometrial cancer |
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Leukemia |
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Lung cancer |
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Non-Hodgkin lymphoma |
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Hodgkin lymphoma |
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Pancreatic cancer |
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Thyroid cancer Other |
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Other |
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Sum |
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Overall score |
Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.
Diseases of the Immune System
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Score 0 if none, otherwise 1 for each disease or disorder noted, and for each relative category |
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Siblings |
Parents |
Cousins |
Uncle/Aunts |
Grandparents |
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Immunodeficiency diseases & disorders |
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Bruton's disease |
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DiGeorge syndrome |
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Job syndrome |
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X-linked agammaglobulinemia |
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Common variable immunodeficiency |
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Immune-complex disease |
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Other |
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Autoimmune diseases & disorders |
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Addison disease |
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Celiac disease |
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Hashimoto thyroiditis |
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Lupus erythematosus |
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Myasthenia gravis |
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Psoriasis/psoriatic arthritis |
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Sjogren syndrome |
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Autoimmune vasculitis |
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Grave's disease |
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Inflammatory bowel disease |
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Multiple sclerosis |
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Pernicious anemia |
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Rheumatoid arthritis |
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Other |
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Sum |
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Overall score |
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Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.
Diseases of the Skin, Bones, Joints & Muscles
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Score 0 if none, otherwise 1 for each disease or disorder noted, and for each relative category |
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Siblings |
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Parents |
Cousins |
Uncle/Aunts |
Grandparents |
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Skin diseases & disorders |
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Adult acne |
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Cold sores |
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Eczema |
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Psoriasis |
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Seborrheic dermatitis |
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Cellulitis |
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Dermatomyositis |
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Hives |
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Rosacea |
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Shingles |
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Other |
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Bone and joint diseases & disorders |
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Bursitis |
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Gout |
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Osteogenesis imperfecta |
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Spinal stenosis |
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Fibrous dysplasia |
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Osteoarthritis |
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Osteoporosis |
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Tendinitis |
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Other |
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Muscular diseases & disorders |
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Amyotrophic lateral sclerosis |
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Dermatomyositis |
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Inclusion body myositis |
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Polymyositis |
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Becker muscular dystrophy |
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Duchenne muscular dystrophy |
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Myasthenia gravis |
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Other |
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Sum |
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Overall score |
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Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.
Renal & Gastrointestinal Diseases
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Score 0 if none, otherwise 1 for each disease or disorder noted, and for each relative category |
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Siblings |
Parents |
Cousins |
Uncle/Aunts |
Grandparents |
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Kidney diseases & disorders |
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Kidney failure |
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Chronic kidney disease |
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Polycystic kidney disease |
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Acetaminophen nephrotoxicity |
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Kidney injury |
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Nephroma/Nephropathy/Necrosis |
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Other |
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Gastrointestinal diseases & disorders |
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Colon polyps |
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Diverticular disease |
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Ischemic colitis |
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Crohn's disease |
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Irritable bowel syndrome |
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Ulcerative colitis |
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Other |
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Sum |
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Overall score |
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Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.
Cardiovascular System & Respiratory Diseases
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Score 0 if none, otherwise 1 for each disease or disorder noted, and for each relative category |
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Siblings |
Parents |
Cousins |
Uncle/Aunts |
Grandparents |
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Heart diseases & disorders |
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Bradycardia |
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Tachycardia |
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Congestive heart failure |
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Dilated cardiomyopathy |
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High cholesterol |
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Low blood pressure |
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Mitral valve prolapse |
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Fibrillation Congenital heart disease |
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Coronary heart disease |
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High blood pressure |
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Hypertrophic cardiomyopathy |
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Mitral regurgitation |
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Pulmonary stenosis |
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Other |
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Strokes |
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Brain stem strokes |
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Hemorrhagic |
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Transient ischemic attack (mini stroke) |
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Ischemic stroke (clot) |
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Cryptogenic stroke (unknown cause) |
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Other |
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Lung diseases & disorders |
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Asthma |
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COPD |
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Emphysema |
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Pneumonia |
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Tuberculosis |
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Chronic bronchitis |
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Cystic fibrosis |
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Pleural effusion |
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Pulmonary hypertension |
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Other |
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Blood diseases & disorders |
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Anemia |
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Kostmann syndrome |
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Von Willebrand disease |
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Hemophilia |
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Sickle cell disease |
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Beta thalassemia |
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Other |
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Sum |
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Overall score |
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Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.
Disease of Central Nervous System
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Score 0 if none, otherwise 1 for each disease or disorder noted, and for each relative category |
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Siblings |
Parents |
Cousins |
Uncle/Aunts |
Grandparents |
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Intellectual disabilities |
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Apert syndrome |
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Down syndrome |
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Fragile-X syndrome |
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Low IQ |
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Cerebral palsy |
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Fetal alcohol syndrome |
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Prader-Willi syndrome |
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Williams syndrome |
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Other |
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Neurological diseases & disorders |
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Alzheimer |
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Brain & Spinal cord tumors |
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Cervical spondylosis |
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Encephalitis |
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Epilepsy |
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Huntington’s chorea |
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Meningitis |
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Neuralgia |
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Parkinson's disease |
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Bell's palsy |
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Carpal tunnel syndrome |
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Dementia |
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Epidural abscess |
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Guillain-Barre syndrome |
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Hydrocephalus |
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Multiple sclerosis |
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Neuropathy |
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Other |
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Mental illnesses |
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Anorexia nervosa |
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Borderline personality disorder |
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Depression |
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Obsessive compulsive disorder |
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Phobias |
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Social anxiety disorder |
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Bipolar affective disorder |
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Bulimia nervosa |
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Generalized anxiety disorder |
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Panic disorder |
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Schizophrenia and other psychoses |
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Other |
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Sleep disorders |
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Hypersomnia/narcolepsy |
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Night terrors |
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Restless leg syndrome |
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Sleep paralysis |
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Sleep talking |
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Insomnia |
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Nocturia |
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Sleep apnea |
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Sleepwalking |
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Other |
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Sum |
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Overall score |
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Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.
Eye Diseases
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Score 0 if none, otherwise 1 for each disease or disorder noted, and for each relative category |
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Siblings |
Parents |
Cousins |
Uncle/Aunts |
Grandparents |
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Ocular diseases & disorders |
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Astigmatism |
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Blue-yellow color blindness |
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Red-green color blindness |
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Diabetic retinopathy |
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Glaucoma |
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Cataract |
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Macular degeneration |
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Amblyopia (Lazy eye) |
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Far or near sightedness |
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Strabismus (Cross eye) |
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Trauma or injury |
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Other |
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Sum |
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Overall score |
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Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.
"Prevention is better than cure" Desiderius Erasmus