Instructions: Family History Diagram & Information Sheet

Medical Genetics, University of Kansas Medical Center

Instructions Family History Diagram and Information Sheet

Your appointment will include a careful survey of your family's medical history. As patients often find that the details of this history take time to recall, we ask you to prepare the attached form before coming to the Genetics Clinic. This will allow us more time for discussion and will enable us to provide you with the most accurate information.

Completing a Medical Information Form and bringing a photograph of the affected family member may be helpful as well.

1. To complete the Family History Diagram Form, please use the following symbols:

For additional symbols, see: Pedigree Standardization Task Force Recommendations, American Journal of Human Genetics (1995), 56:745-752

Female - circle

Male - square

Marriage - square connected by horizontal line (marriage line) to circle

Divorce - diagonal line through marriage line

Children - circles and/or squares placed below horizontal line (offspring line) below marriage line. [marriage line and offspring line connected by verticle line]

Pregnancy - incompletely connected diamond shape

Miscarriage - small filled-in circle

Twins - connected to offspring line by upside down "V"

Stillbirth or Death - small circle or square with diagonal line through symbol

2. When filling out the diagram, note the "individual" and the "family" name at each marriage. If at all possible, diagram the pregnancies from the first to the last in the order in which they occurred, including all miscarriages and stillbirths. Include all individuals with birth defects.

3. Indicate the "affected" person with an arrow.

4. Draw 3 generations on the Family History Diagram:

* Assign each individual a different number.

* List all brothers and sisters of the patient (including half-brothers/ half-sisters).

* List all brothers and sisters of the patient's parents.

* List all children of the parent's brothers and sisters (the patient's cousins).

* List maternal and paternal grandparents.

* List other relatives you feel might have related conditions.

5. For each individual on the diagram (especially, family members related to the person for which you are coming to the Genetics Clinic), record information about them on the Family Names List:

List their name and date of birth.

List all serious, chronic, or recurrent illnesses or abnormalities such as:

* birth defects (specify)

* short stature (state height)

* deafness/hearing impairment (indicate conductive or neurologic)

* eye problems

* developmental delay / mental retardation

* muscle disease

* kidney problems

* endocrine problems, diabetes

* mental disorders

* heart defects (specify)

* bone or joint problems

* cancer or tumors (list type, location, and age diagnosed)

* miscarriage / stillbirth (indicate month of pregnancy)
List all causes of death, if known, and age at time of death.

6. Note your relatives' country of origin.

Forms needed for completion of family history:

Family History Diagram /gec/famhx/famped.doc (WORD document)

Medical Information Form /gec/famhx/medinffm.html

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