This is a Family Medical History Questionnaire, to be used by the Family Court in the State of Wisconsin. This form is used to comply with 767.24(7m) and 767.51(3r), which requires the court to order a noncustodial parent or both parents, to complete a medical history questionnaire.
Wisconsin Family Medical History Questionnaire
Category:
State:
Wisconsin
Control #:
WI-FA-608
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Word;
PDF;
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Description
How to fill out Wisconsin Family Medical History Questionnaire?
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If possible, your family medical history should include at least three generations. Compile information about your grandparents, parents, uncles, aunts, siblings, cousins, children, nieces, nephews and grandchildren. For each person, try to gather the following information: Sex.
What Are Your Medical and Surgical Histories? What Prescription and Non-Prescription Medications Do You Take? What Allergies Do You Have? What Is Your Smoking, Alcohol, and Illicit Drug Use History? Have You Served in the Armed Forces?
How to Access this Information. The easiest way to access your family's medical history is to talk to your parents, siblings and other relatives about their health. Ask them about their disease history, their lifestyle habits and what medications they take for which conditions.
A record of information about a person's health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
Questions can include o Do you have any chronic diseases, such as heart disease or diabetes, or health conditions such as high blood pressure or high cholesterol? o Have you had any other serious diseases, such as cancer or stroke? o How old were you when each of these diseases and health conditions was diagnosed? o
Use a filing cabinet, 3-ring binder, or desktop divider with individual folders. Store files on a computer, where you can scan and save documents or type up notes from an appointment. Store records online using an e-health tool; certain online records tools may be accessed, with permission, by doctors or family members.
Include information on major medical conditions, causes of death, age at disease diagnosis, age at death, and ethnic background. Be sure to update the information regularly and share what you've learned with your family and with your doctor.
How old are you? Do you or did anyone in our family have any long-term health problems, like heart disease, diabetes, kidney disease, bleeding disorder, or lung disease? Do you or did anyone in our family have any health issues like high blood pressure, high cholesterol, or asthma?