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Health History Questionnaire – Family Medicine. Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions.Please complete this entire questionnaire. Understand the importance of gathering a complete and accurate family medical history from your patients and find tools to simplify the process. Describe when it started and how it started, symptoms, medications taken and results. Who are the doctors involved in your medical care? If you are agreeable to providing your family history related to heart disease, please complete the following table and sign below. If you are being referred for genetic evaluation for your child, complete this Family History Questionnaire for Child and bring it to your Genetics appointment. Patient Name: Date of Birth: Sex: (circle). Health History Questionnaire.