Cardiology Family History Questionnaire

Name ______

Date of Birth ______Gender Male ____ Female ____

Phone (H) ______(W) ______

What is your ethnicity?

____ White/Caucasian ____ Black/African American ____ Asian

____ Hispanic/Latin ____ South Pacific Islander ____ Native American Indian

____ Other

Are you adopted? ____ Yes ____ No ____ Don’t know

Your answers to the following questions will help us evaluate your risk of developing cardiac problems. This will help your cardiologist provide better care for you. We are interested in any cardiac abnormalities in a blood relative. Please include any details about diagnoses for boxes checked in the comments column. If necessary, please feel free to write on the back side of this form.

Please check the box in the appropriate column if any of your family members have the listed conditions.

Disease/Condition / Self / Mother / Father / Children / Brothers & Sisters (including half brothers and sisters) / Grandparents / Aunts, Uncles and Cousins
An enlarged (big) heart or cardiomyopathy
Sudden unexpected death at or before age 40
Disease/Condition / Self / Mother / Father / Children / Brothers & Sisters (including half brothers and sisters) / Grandparents / Aunts, Uncles and Cousins
Aneurysm of aorta
Surgery on aorta
Ruptured aneurysm or dissection
Aneurysm in brain
Aneurysm elsewhere in body
Diagnosed with or suspected of having Marfan syndrome
Diagnosed with or suspected of having Ehlers Danlos syndrome
Diagnosed with or suspected of having Loeys-Dietz syndrome
Disease/Condition / Self / Mother / Father / Children / Brothers & Sisters (including half brothers and sisters) / Grandparents / Aunts, Uncles and Cousins
Heart valve abnormality (ie. bicuspid aortic valve or mitral valve prolapse)
Pacemaker or defibrillator
Hypertension or High Blood Pressure
Stroke/TIA at or before age 60
Stroke/TIA after age 60 or unknown age
High cholesterol
Heart attack at or before age 40
Heart attack after age 40
Coronary artery disease
Disease/Condition / Self / Mother / Father / Children / Brothers & Sisters (including half brothers and sisters) / Grandparents / Aunts, Uncles and Cousins
Diabetes
Heart defect at birth
Muscle disorder or muscular dystrophy

Any other problems related to the heart not mentioned above?

Other diseases that run in your family not mentioned above? ____ Yes ____ No

If Yes, please explain.

Are you concerned that you could be at risk for any of these diseases running in your family? ____ Yes ____ No

Have you ever been referred to or seen by genetics or a genetic counselor? ____ Yes ____ No

Have you or a family member had any genetic testing related to disease in your family? ____ Yes ____ No

2009