Family history questionnaire (three generations)
For the patient or caregiver to complete before the appointment.
Patient name or ID
Date
Completed by (relationship to patient)
Please list blood relatives over three generations: brothers and sisters, parents, aunts and uncles, grandparents, and children. Write “not known” where you are unsure; do not guess.
| Relative (e.g. mother, maternal aunt) | Sex | Alive / deceased (age) | Similar or other health problems | Age when it started | Genetic test done? |
|---|---|---|---|---|---|
Questions about the family
Are the patient’s parents related by blood (for example cousins)? ☐ Yes ☐ No ☐ Not known If yes, how: ____________________
Number of miscarriages in the family (who)
Stillbirths or deaths in infancy (who)
Mother’s age at the patient’s birth
Father’s age at the patient’s birth
Countries or regions the family comes from (optional)
Any known genetic condition in the family, and who has it
Anything else you think is important
Your answers are used to draw a family tree (pedigree). Relatives are identified by relationship only unless you choose to give names.
© Tribro-Omics · Family history questionnaire (three generations) · Version 1.0 · 11 November 2026