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Funded by:Illinois Department of Public Health
Family Health History Is Important!A recent survey found that 96% of Americans believe that knowing their family health history is important.
Diseases which may be present in your family:
• Cancer
• Heart disease
• Kidney disease
• Emotional disorders
• Down Syndrome
• Diabetes
• Genetic disorders
• Bleeding disorders
Family Health History
RECORD KEEPER
The Family Health History Initiative is a cooperative effort by the Center for Jewish Genetics and the Illinois
Department of Public Health.
Center for Jewish Genetics30 South Wells Street
Chicago, IL 60606-5056
(312) [email protected]
www.jewishgenetics.orgThe Center for Jewish Genetics is a program
of the Jewish United Fund of Metropolitan Chicago.
Illinois Department of Public Health Genetics Program
535 West Jefferson Street, 2nd FloorSpringfield, IL 62761
(217) 785-8101TTY (hearing impaired use only): (800) 547-0466
http://dph.illinois.gov/topics-services/ life-stages-populations/genomics
DNA DAY RECORD KEEPER_gs.indd 1-3 3/11/16 1:15 PM
Health History on My Mother’s SideMother: __________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Grandmother: ____________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Grandfather: _____________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Aunts:____________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Uncles: ___________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Cousins: _________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Health History on My Father’s SideMother: _________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Grandmother: ___________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Grandfather: ____________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Aunts:___________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Uncles: __________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Cousins: ________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
My Family Health HistoryMy Health Conditions: ______________________
____________________________________________
____________________________________________
____________________________________________
My Children: _______________________________
____________________________________________
____________________________________________
My Sisters: _________________________________
____________________________________________
____________________________________________
My Brothers: _______________________________
____________________________________________
____________________________________________
My Nieces: _________________________________
____________________________________________
My Nephews: _______________________________
____________________________________________
DNA DAY RECORD KEEPER_gs.indd 4-6 3/11/16 1:15 PM