Family History

Cardiovascular Family history

Family history

You have been sent this questionnaire to record your family history. This is useful information for your doctor because:

  1. It can help your doctor plan care for you in the future
  2. It can be taken into account when looking at your cardiovascular risk
  3. It can help your doctor to plan if any additional screening or care is needed

Please answer the following questions and put in details of your own family history

When recording family history health professionals treat half brothers/sisters exactly as they would brothers or sisters.
Please record any details of half brothers/sisters family history as a brother or sister in the following questions.

Identification Questions

In order to identify patients correctly, we would like you to answer the following questions.

Identification Questions

In order to identify patients correctly, we would like you to answer the following questions.

If you have an NHS login, use it now and save time on filling in some details.



Are you the patient? *

Additional information

Please could you give us your own details first and then provide the patients details

Now can you enter the patients details:

Gender *
Preferred contact: *
Preferred contact:

Please note that the sick note will be sent via email.

Cardiovascular family history

Does anyone in your family have angina (a heart blood supply problem) or has anyone in your family had a heart attack, stroke, mini-stroke or a TIA (transient ischaemic attack)?

Please fill in the following

For each member of your family who has a history of these problems, please complete the details below.
Add further members of your family by clicking “add” after the question about the age of the person affected

Details:

Add one entry per family member and select all problems that they have.
Please select the relationship:
Please select the relationship:
Was this person over or under the age of 50 when they first had any of these problems?
Was this person over or under the age of 60 when they first had any of these problems?
If any other family member has had one or more of these problems, please click the ‘+Add’ link below to record this.

Thank you

The information you have entered will be sent to your GP surgery and recorded in your records