Family Genetic History Intake Form
Purpose
The purpose of this assignment is to understand the implications of genetics on an individual’s health and potential risk for disease. You are to obtain a family genetic history on a non-related adult participant.
Important – When taking a family genetic history it is very important that the information be accurate. Please inform your participant that they have the right to refuse to share information with you. If the adult participant exercises this right, please write in the appropriate spot “Does not want to disclose information.”
Directions
Develop a family genetic history that includes, at a minimum, three generations of your chosen adult’s family, including grandparents, parents, and the adult’s generation. If the adult has any children, include them as the fourth generation. **PLEASE NOTE: This assignment is to reveal the potential impact of the family’s health on the adult participant. You do not need to identify anyone who is not biologically related to the adult except for a spouse or significant other.
You do not need to use symbols, but instead write brief descriptions for each person using the chart below. Each description should include the following information: first name, birthdate, death date, occupation, education, primary language, and a health summary, including any medical diagnoses. Indicate if any information is not applicable or unknown. Remember if the individual does not want to disclose the information please write “Does not want to disclose” in the appropriate line. Here is an example of part of a completed form:
Family Member Description
Paternal grandfather
First and last initials: NS
Birthdate: 1920
Death date: 1979
Occupation: Retired as a truck driver
Education: 6th grade
Primary language: English
Health summary: He was diagnosed with heart disease, diabetes, and hypertension. He died from a heart attack.
Paternal grandmother
First and last initials: DT
Birthdate: 1928
Death date: 1988
Occupation: House wife
Education: Does not want to disclose
Primary language: English
Health summary: Diagnosed with chronic obstructive pulmonary disease, heart disease and obesity. Died from heart failure.

Genetic History Form
Family Member Description
Paternal grandfather
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Paternal grandmother
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Father
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Father’s siblings (write a brief summary of any significant health issues)
Maternal grandfather
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Maternal grandmother
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Mother
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Mother’s siblings (write a brief summary of any significant health issues)
Adult Participant
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Adult participant’s siblings (write a brief summary of any significant health issues)
Adult participant’s spouse/significant other
First and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Adult participant’s children (write a summary for each child, up to four children)
Child #1 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Child #2 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Child #3 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:
Child #4 first and last initials:
Birthdate:
Death date:
Occupation:
Education:
Primary language:
Health summary:

2. Evaluation of family genetic history
Evaluate the impact of the family’s genetic history on your adult participant’s health. For example, if the adult participant’s mother and both sisters have depression, hypertension, or cancer, what might that mean for the adult participant’s future health?
3. Planning for health maintenance/promotion
Plan changes based on the evaluation of the adult participant’s family’s health history that will promote an optimal level of health now and to promote health in the future. Provide evidence for health promotion activities (consider Healthy People 2030 goals, health.gov and other types of evidence) Include what information you would provide to the adult participant regarding the results of the family genetic history.