S C R E E N

Taking a Family History

for Familial Disease
The following set of questions can be used by a physician or
clinician as a primary prevention tool.

SC

Some Concerns

Question: Do you have any (some) concerns about diseases or conditions

that seem to run in the family?

Reproduction

Question: Have there been any problems with pregnancy, infertility or birth
defects in your family?

Early disease, death or disability

Question: Have any members of your family been diagnosed with a chronic
disease at an early age or have members of your family died at an early age?

Ethnicity

Question: How would you describe your ethnicity? Or Where were your
grandparents born?

Non-Genetic Conditions

Question: Are you aware of any non-medical conditions or risk factors, like
smoking or problem drinking that are present in your family?