Table 3.
Fill-in family history forms | Available in Spanish | Disease focus | Document complexity level |
---|---|---|---|
ADHD Support: | |||
Apples on the Family Tree (Family Tree) | No | ADHD | Level 2 proficiency – low complexity |
American Heart Association: | |||
Go Red for Women Family Tree | Yes | Heart disease | Level 2 proficiency – low complexity |
American Heart Association: | |||
The Heart of Diabetes | No | Diabetes | Level 2 proficiency – low complexity |
American Heart Association – Wisconsin Stroke Committee | |||
Reproducible Family Health History Tree | No | Stroke and high blood pressure | Level 2 proficiency – low complexity |
American Medical Association: | |||
Adult Family History Form | No | Multiple | Level 3 proficiency – moderate complexity |
Aurora Health Care: | |||
Hereditary Cancer Risk Assessment Tool | No | Cancer | Level 2 proficiency – low complexity |
Centre for Genetics Education of the NSW Genetics Service | |||
Family Health History Can Matter (My Family Health Record) | No | Multiple | Level 1 proficiency – very low complexity |
Genetic Alliance: | |||
Family Health History Questionnaire | No | Multiple | Level 2 proficiency – low complexity |
Genetics in Primary Care (GPC) project, Family History Working Group: | |||
Genetic Tools Family Disease Checklist | No | Multiple | Level 4 proficiency – high complexity |
Genetics in Primary Care (GPC) project, Family History Working Group: | |||
Your Family Medical History | No | Multiple | Level 3 proficiency – moderate complexity |
Howard University – National Human Genome Center: | |||
Planning for a Healthy Future: The Importance of Family Health History (Family Health History Tree) | No | Multiple | Level 3 proficiency – moderate complexity |
Indiana University School of Medicine Department of Medical Genetics | |||
Family History Questionnaire | No | Multiple | Level 4 proficiency – high complexity |
Lahey Clinic Foundation Familial Cancer Risk Assessment Center: | |||
Cancer Risk Evaluation Packet | No | Cancer | Level 4 proficiency – high complexity |
March of Dimes: | |||
Family Health Questionnaire (Prenatal) | Yes | Prenatal syndromes | Level 4 proficiency – high complexity |
Michigan Department of Community Health: | |||
Family History and High Blood Pressure | No | Blood pressure | Level 2 proficiency – low complexity |
National Breast Cancer Centre: | |||
Family History Questionnaire | No | Breast cancer | Level 2 proficiency – low complexity |
National Coalition for Health Professional Education in Genetics: | |||
Family History Questionnaire | No | Multiple | Level 4 proficiency – high complexity |
New York State Department of Health: | |||
Sample Cancer Family History Questionnaire | No | Cancer | Level 2 proficiency – low complexity |
Prevent Cancer Foundation: | |||
Guide to Preventable Cancer (Family Medical History Chart) | No | Cancer | Level 2 proficiency – low complexity |
Princess Margaret Hospital: | |||
Family History Questionnaire | No | Cancer | Level 4 proficiency – high complexity |
U.S. Surgeon General's Family History Tool: | |||
My Family Health Portrait (paper version) | Yes | Multiple | Level 3 proficiency – moderate complexity |
University of Bristol: | |||
The Questionnaire | No | Colorectal cancer | Level 1 proficiency – very low complexity |
University of Chicago: | |||
Cardiology Family History Questionnaire | No | Cardiovascular disease | Level 4 proficiency – high complexity |
University of Virginia Health Systems: | |||
Are You at Risk for Hereditary Breast Cancer? | No | Breast and ovarian cancer | Level 2 proficiency – low complexity |
Utah Department of Health: | |||
Health Family Tree Tool | Yes | Multiple | Level 2 proficiency – low complexity |
Note: Grade level equivalent range for proficiency levels. Level 1: grade 4 equivalent to less than 8 years of schooling; Level 2: grade 8 equivalent to high school diploma; Level 3: grade 12 equivalent to some education after high school; Level 4:15 years of schooling to college degree equivalent; Level 5: 16 years of schooling to more advanced postgraduate degree.