Draft 1/12/03  

This tool is in the early stages of development. Substantial changes are likely regarding terminology, layout, instructions, diseases
included or excluded, and relatives included or excluded.  

Family History Survey
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1. Today’s Date:___________ Date of Birth:__________  
2. Gender: Male_____ Female_____  
3. What is your race/ethnicity?                                 
___White/Caucasion
 ___Black/African ___Asian
___Hispanic/Latin     
___South Pacific Islander ___Native American Indian
___Other                 
    
4. Are you Central or Eastern European (Ashkenazi) Jewish?  
Yes____ No____ Don’t Know___
5. Are you adopted?
Yes____ No____ Don’t Know___
     
Please check the appropriate box if you or your relatives have had any of the disease/conditions listed in the table below. Be sure to check the box for the appropriate age at disease onset.

   
Self
Mother
Father
Children
Brothers & Sisters (including half brothers and sisters)
Nieces & Nephews
Father's sisters, brothers, and parents (your grandparents)
Mother's sisters,brothers, and parents (your grandparents)
Disease/Condition
      
One
Two or more
One
Two or more
One
Two or more
One
Two or more
One
Two or more
Coronary heart disease
  at or before age   60		                          
  after age 60 or   unknown age                          
Sudden unexpeced death
  at or before age 40		                          
  after age 40 or   unknown age                          
Stroke/TIA (mini stroke)
  at or before age 60		                          
  after age 60 or   unknown age                          
Hypertension/high blood pressure
  at or before age 40		                          
  after age 40 or   unknown age                          
Diabetes
  at or before age 20		                          
  after age 20 or   unknown age                          
Blood clots in lungs or legs
  at or before age 40		                          
  after age 40 or   unknown age                          
Emphysema/Lung disease (not cancer)
  at or before age 50		                          
  after age 50 or   unknown age                          
Kidney disease (not cancer)
  at or before age 50		                          
  after age 50 or   unknown age                          
Other diseases that run in the family:
________________

________________

________________

                          
Breast cancer in females
  at or before age 50		                          
  after age 50 or   unknown age                          
Breast cancer in males
  at or before age 50		                          
  after age 50 or   unknown age                          
Ovarian cancer
  at or before age 50		                          
  after age 50 or   unknown age                          
Prostate cancer
  at or before age 50		                          
  after age 50 or   unknown age                          
Colon/colorectal cancer
  at or before age 50		                          
  after age 50 or   unknown age                          
Endometrial cancer
  at or before age 50		                          
  after age 50 or   unknown age                          
Thyroid cancer
  at or before age 50		                          
  after age 50 or   unknown age                          
Kidney cancer
  at or before age 50		                          
  after age 50 or   unknown age                          
Other cancers that run in the family:
________________

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