public health

Name Section------- Date---------

(/ WELLNESS WORKSHEET 8

~Create a Family Health Portrait The Surgeon General's Family History Initiative encourages all American families to learn more about their family history. Knowing your family health history is a powerful guide to understanding risk for disease. However, keep in mind that a family history of a particular illness may increase risk, but it almost never guarantees that other family members will develop the illness.

To get the most accurate health history information, it is important to talk directly with your relatives. Explain to them that their health information can help improve prevention and screening of diseases for all family members.

Start by asking your relatives about any health conditions they have had-including history of chronic ill- nesses, such as heart disease; pregnancy complications, such as miscarriage; and any developmental disabili- ties. (You may want to refer to Wellness Worksheet 45 for a list of conditions and diseases.) Get as much specific information as possible. It is most useful if you can list the formal name of any medical condition that has affected you or your relatives. You can get help finding information about health conditions that have affected you and your family members-living or deceased-by asking relatives or health care professionals for information or by getting copies of medical records. If you are planning to have children, you and your partner should each create a family health portrait and show it to your health care professional.

The Family Health Portrait chart on the following pages will help you collect and organize your family infor- mation. (You can also complete a family health history at http://familyhistory.hss.gov.) No form can reflect every version of the American family, so use this chart as a starting point and adapt it to your family's needs. First, complete the personal information, including the number of relatives you have in each category and whether you have any of the six conditions listed. Then complete the family information, including any health conditions your family members have, their age at diagnosis, and, if they are deceased, the age at which they died. Because some conditions are more common in people with certain ethnic ancestries, you may also want to record your relatives' ancestry or country of origin under their names.

Once you complete the Family Health Portrait, take it to your health care professional so that he or she can better individualize your health care. Be sure to make a copy for your records and update it as circumstances change or you learn more about your family's health history.

Inset/Roth, Connect Core Concepts in Health, Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter I lnsei/Roth, Connect Core Concepts in Health, BriefTwelfth Edition © 20 12 The McGraw-Hill Companies, Inc. Chapter I

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WELLNESS WORKSHEET 8 - continued

PERSONAL INFORMATION

Name: (Last) _____________ _

(First) _____________ _

Date of Birth

Are you an identical twin?

Record the number of family members you have in the box below. These are the family members who are most relevant to your health history.

NUMBER OF FAMILY MEMBERS

Related by blood, living or deceased

GRANDPARENTS: 4 MoTHER: 1 FATHER: 1 AUNTs:

UNCLES:

SISTERS:

BROTHERS:

DAUGHTERS:

SoNs:

HALF SISTERS:

HALF BROTHERS;

Yes_ No_

Record whether you have any of the 6 conditions listed below. These diseases are tracked because they are common and we have very good information about how to avoid them.

In the spaces labeled "Other," enter other diseases or conditions you have.

Do YOU HAVE ANY YEs/No

AGE AT OF THESE HEALTH CONDffiONS? DIAGNOSIS

HEART DISEASE

STROKE

DIABETES

CoLON CANCER

BREAST CANCER

OVARIAN CANCER

~ £-< 0

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WELLNESS WORKSHEET 8 - continued

Family Infonnation

List below your blood relatives and the illnesses they may have suffered, even if you do not know the medical name. Refer back to the box, "Number of Family Members" so you don't forget anyone. Fill in as much information as you can. Be sure to report diseases such as heart disease, stroke, diabetes, or cancer (especially colon, breast, or ovarian cancers) that have occurred in your family.

FAMILY RELATIONSHIP TWIN? AGE AT LIVING? AGE (BWOD REU\TED ONLY)

RELATIVE's NAME TO YOU (YIN) HEALTH CONDITION DIAGNOSIS (YIN) AT DEATH

IMMEDIATE

(brothers, sisters, parents, children)

MoTHER's (her father; her mother; her sisters,

her brothers)

Inset/Roth, Connect Core Concepts in Health, Twelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter I lnsei/Roth, Connect Core Concepts in Health, BriefTwelfth Edition © 2012 The McGraw-Hill Companies, Inc. Chapter I

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WELLNESS WORKSHEET 8 - continued

FAMILY RELATIVE'S NAME

RELATIONSIDP TwiN? AGE AT LIVING? AGE (BWOD REl-ATED ONLY) TO YOU (YIN) HEALTH CONDITION DIAGNOSIS (YIN) AT DEATH

MoTHER's CONTINUED

FATHER'S

(his father, his mother, his sisters,

his brothers)

SOURCE: Department of Health and Human Services. 2007. The Surgeon General's Family History Initiative: My Family Health Portrait (http:/lwww.hhs.gov/familyhistory; retrieved November 19, 2008).