Family Medical History Template 2026
Free printable family health history forms, pedigree chart templates, and genetic history questionnaires. Essential tools for identifying hereditary risk factors and guiding preventive care.
Key Takeaways
- Three-generation history is the minimum standard (parents, siblings, grandparents)
- Pedigree charts visually identify inheritance patterns for genetic conditions
- Update annually or when major family health events occur
- Refer for genetic counseling when patterns suggest hereditary risk
Why Family Medical History Matters
Family medical history is one of the most powerful tools for predicting disease risk. Genetic factors contribute to the majority of chronic diseases, including heart disease, diabetes, and many cancers. A thorough family history can identify patients who need earlier screening, more frequent monitoring, or genetic testing.
of cancers have hereditary component
increased risk with first-degree relative affected
of patients want genetic information shared
Clinical Value of Family History
- • Risk stratification: Identify high-risk patients for enhanced screening
- • Early detection: Begin colonoscopy, mammography earlier based on family history
- • Prevention: Lifestyle counseling for at-risk patients
- • Genetic testing: Determine who should be offered BRCA, Lynch syndrome testing
- • Cascade testing: Identify at-risk family members after positive genetic test
What Information to Collect
For Each Family Member
Basic Information
- • Relationship to patient
- • Current age (or age at death)
- • Cause of death (if applicable)
- • Ethnicity/ancestry
Health Information
- • Major medical conditions
- • Age at diagnosis
- • Surgical history
- • Known genetic test results
Relatives to Include (Three Generations)
First Degree
- • Parents
- • Siblings
- • Children
Second Degree
- • Grandparents
- • Aunts & Uncles
- • Half-siblings
- • Nieces & Nephews
Third Degree
- • Great-grandparents
- • First cousins
- • Great aunts/uncles
Key Conditions to Document
Cardiovascular
- • Heart attack (age?)
- • Stroke (age?)
- • High blood pressure
- • High cholesterol
- • Sudden cardiac death
Cancer
- • Type of cancer
- • Age at diagnosis
- • Multiple cancers?
- • Bilateral breast cancer?
- • Known BRCA/Lynch mutation?
Metabolic
- • Diabetes (Type 1 or 2?)
- • Obesity
- • Thyroid disorders
- • Hemochromatosis
Neurological/Mental Health
- • Dementia/Alzheimer's
- • Parkinson's disease
- • Depression/Bipolar
- • Suicide
- • Substance use disorders
Family History Questionnaire Template
Family Medical History Form
Page 1 of 2Patient Information
Name: _______________________________
Date of Birth: _______________________
Date: _______________________________
Ethnicity: ___________________________
Mother's Side of Family
Father's Side of Family
Siblings
Number of brothers: _____ Ages: _____________________________
Number of sisters: _____ Ages: _____________________________
Health conditions in siblings: ________________________________
Download Options
For a printable PDF version of this questionnaire, consider using the CDC's "My Family Health Portrait" tool or your EHR's built-in family history module.
Pedigree Chart Template & Symbols
Standard Pedigree Symbols
Basic Symbols
Relationship Symbols
Pedigree Chart Structure
Generations are arranged in horizontal rows:
- • Generation I (top): Grandparents
- • Generation II (middle): Parents, aunts, uncles
- • Generation III (bottom): Patient (proband), siblings, cousins
- • Generation IV: Children of proband
Draw maternal relatives on the left, paternal on the right. Connect siblings with horizontal lines at the same level.
Condition-Specific Screening Questions
Cancer Family History (HBOC/Lynch Risk)
Ask about the following red flags:
- □ Breast cancer diagnosed before age 50?
- □ Ovarian cancer at any age?
- □ Male breast cancer?
- □ Triple-negative breast cancer?
- □ Bilateral breast cancer?
- □ Pancreatic cancer?
- □ Colon cancer before age 50?
- □ Endometrial cancer before age 50?
- □ Multiple cancers in same person?
- □ Known BRCA1/2 or Lynch mutation?
- □ Ashkenazi Jewish ancestry?
- □ Multiple family members with cancer?
Cardiac Family History
- □ Heart attack before age 55 (male) or 65 (female)?
- □ Sudden cardiac death under age 50?
- □ Cardiomyopathy?
- □ Long QT syndrome?
- □ Arrhythmia requiring treatment?
- □ Need for pacemaker/ICD?
- □ Aortic aneurysm?
- □ Marfan syndrome?
Pregnancy/Reproductive History (ACOG)
- □ History of birth defects?
- □ Intellectual disability/developmental delay?
- □ Recurrent pregnancy loss (3+ miscarriages)?
- □ Stillbirth?
- □ Known chromosomal abnormality?
- □ Consanguinity (related parents)?
- □ Cystic fibrosis?
- □ Sickle cell disease/trait?
- □ Tay-Sachs disease?
- □ Thalassemia?
When to Refer for Genetic Counseling
Refer When Family History Shows:
Cancer Risk
- • Breast cancer <50 years
- • Ovarian cancer any age
- • Triple-negative breast cancer <60
- • Male breast cancer
- • Pancreatic cancer with BRCA history
- • Colon/endometrial cancer <50
- • ≥3 relatives with same cancer
- • Known pathogenic variant in family
Other Indications
- • Sudden cardiac death <50
- • Cardiomyopathy
- • Aortic aneurysm <55
- • Consanguinity
- • Birth defects/developmental delay
- • Recurrent pregnancy loss
- • Early-onset dementia (<65)
- • High-risk ethnic background
Finding a Genetic Counselor
The National Society of Genetic Counselors maintains a directory of certified genetic counselors. Many offer telemedicine appointments.
NSGC Find a Genetic CounselorDigital Family History Tools
My Family Health Portrait (CDC)
Free web-based tool from the Surgeon General. Creates printable pedigree and can export to some EHRs.
- ✓ Free and HIPAA-exempt
- ✓ Creates visual pedigree
- ✓ Exports to HL7 format
- ✓ Patient-facing
EHR Family History Modules
Most major EHRs have built-in family history documentation with structured data capture.
- ✓ Epic: Family History Activity
- ✓ Cerner: Family Health History
- ✓ Athenahealth: Family History tab
- ✓ Supports clinical decision alerts
Progeny Genetics
Clinical pedigree software used by genetic counselors and genetics departments.
- ✓ Publication-quality pedigrees
- ✓ Risk assessment integration
- ✓ EHR integration available
- • Subscription required
Patient Intake Platforms
Digital intake solutions often include family history questionnaires.
- ✓ Phreesia
- ✓ Clearwave
- ✓ Relatient
- ✓ Pre-visit completion
EHR Documentation Tips
Sample Family History Note
FAMILY HISTORY:
Cancer History: Mother with breast cancer at age 48 (deceased at 52). Maternal aunt with ovarian cancer at 55. Maternal grandmother with breast cancer at 62.
Cardiovascular: Father with MI at age 52, HTN. Paternal grandfather deceased at 65 from MI.
Metabolic: Father with type 2 diabetes. Maternal grandfather with T2DM.
Psychiatric: Maternal aunt with depression.
Other: No known genetic syndromes. No consanguinity.
Assessment: Significant breast/ovarian cancer history concerning for HBOC. Referred to genetic counseling for BRCA testing consideration.
Documentation Best Practices
- ✓ Use structured fields when available in your EHR
- ✓ Document age at diagnosis, not just "positive" history
- ✓ Note if family history is unknown (adoption, estrangement)
- ✓ Update annually and document the update date
- ✓ Flag high-risk patterns for clinical alerts
- ✓ Document referral to genetic counseling when indicated
Frequently Asked Questions
What should be included in a family medical history?
A comprehensive family medical history should include three generations (parents, siblings, grandparents, aunts/uncles), major medical conditions, age of diagnosis, age and cause of death, ethnic background, and consanguinity. Key conditions to document include heart disease, cancer, diabetes, mental health disorders, and genetic conditions.
How do you create a family medical history pedigree chart?
A pedigree chart uses standard symbols: squares for males, circles for females, filled shapes for affected individuals, diagonal lines for deceased, and horizontal lines connecting partners. Start with the patient (proband, marked with arrow), add parents above, siblings beside, and children below. Include three generations minimum.
When should a patient be referred for genetic counseling?
Refer for genetic counseling when family history shows: early-onset cancer (<50 years), multiple affected relatives with same cancer, known genetic mutations (BRCA, Lynch), multiple generations affected, rare conditions, consanguinity, multiple pregnancy losses, or birth defects. ACOG recommends offering genetic testing based on these criteria.
What is a three-generation family history?
A three-generation family history documents health information for the patient, their parents and siblings (first degree), grandparents, aunts, uncles, and cousins (second degree), and sometimes great-grandparents (third degree). This helps identify hereditary patterns and genetic risk factors.
How often should family medical history be updated?
Family medical history should be updated annually at wellness visits or when significant family health events occur (new diagnoses, deaths, births). The Surgeon General recommends reviewing family history at Thanksgiving gatherings. EHRs should flag patients for periodic updates.
What are the ACOG recommendations for family history in pregnancy?
ACOG recommends collecting three-generation family history at the first prenatal visit covering: genetic conditions, birth defects, intellectual disability, recurrent pregnancy loss, ethnic-specific conditions (Tay-Sachs, sickle cell), and consanguinity. Patients with concerning histories should be offered genetic counseling and carrier screening.
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