Family Medical History
A family medical history is a private list of conditions in parents, siblings, and grandparents that a new doctor often asks about. It is not a diagnosis of anyone on the list, and it is not something to post or to hand to an employer. Relatives may not want their conditions shared. Write what you know and mark what you do not. "I think" is honest. Inventing a relative's illness is not. Bring it to a medical visit. It does not replace the doctor's questions.
For an adult collecting family history for a medical visit. When: before a new-patient appointment, from what relatives have actually told you.
Naming a state changes the note on the page. It does not add that state's required clauses, fees, or font rules. Papero does not invent statutes.
5 lines are still blank. You can still print. Write "not applicable" on a line that does not apply.
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Preview. This is the page that prints.
Family Medical History
You
Relatives
Signature
Signature
Date
Why this form exists, and what it will not do
Family Medical History is for an adult collecting family history for a medical visit. The moment to use it: before a new-patient appointment, from what relatives have actually told you. It sits in the Family and children group on Papero. Permissions, pickup lists, and parenting worksheets. Not court orders.
Fill it in this browser. Papero does not create an account, does not upload the answers, and does not keep a copy after you close the tab. When the preview looks right, print it or download a PDF. The PDF is built on your device. A blank download leaves the lines empty so someone else can fill them by hand.
Work through the page in order. The You section asks for Your name, Date prepared. The Relatives section asks for Parents and siblings, Grandparents, Conditions you were told run in the family.
Your name. The patient this history is for. Date prepared. Today. Parents and siblings. Relationship, and conditions they have told you about.
Grandparents. What you actually know. Write "unknown" where you do not. Conditions you were told run in the family. Name them, and who said so.
People send this back, or refuse it, for ordinary reasons. You guess a diagnosis. You share a relative's details with an employer or a school. Living relatives are named with details they asked you not to spread. Read the finished page once as if you were the person receiving it. If a line would make you call back, fill that line.
Sign on the Signature and Date line. A typed name in the signature spot is weaker than ink on a printed page. Date it the day you sign, not the day you hope the other person signs.
What this page cannot do: This is not a custody order, a divorce paper, or a school district's required form. A permission letter helps when a camp, a school, or an airline accepts a parent letter. If they hand you their slip, use it. A parenting schedule is enforceable when a court enters it or both parents sign the form the court accepts, not when it is only printed. Papero is not a law firm, not a government agency, and not the office that will accept or reject the paper.
State note for your state. Family Medical History does not contain your state's required clauses, font size, language, or filing fee. Counties and cities inside your state sometimes add their own rule on top of the state. Before you rely on this for a lease, a school, a court, a bank, or an agency, compare it with the form that office publishes. If the office has no form, this template is a clear record of what you wrote and what you signed on this date.
After you print, use dark ink. Write "not applicable" on a line that does not apply, so a clerk does not treat a blank as a missing fact. Initial a correction beside the line. Do not cover a dollar amount with correction fluid. Each person who has a signature line signs their own name. One person cannot sign for another unless a statutory power of attorney, on the form that office accepts, already says so. Give the other party a copy the same day. On your copy, note the date and whether you handed it over, mailed it, or uploaded it to their portal. Attach copies of supporting papers, not your only original, unless the office demanded the original. Do not attach a Social Security card, a passport image, or a bank statement unless the recipient told you to, and then only in person or through their secure portal. Email is a common way those images are stolen. If the recipient is a government office, stop and use the form on that office's own site. Papero does not transmit this page, does not notarize it, and does not store it.
Keep a copy. Give the other party a copy. If you later change a fact, fill the form again and date the new copy. Do not scribble a second story into the margin of a page someone already signed. Write the date you handed it over, and how, on your own copy.
Before you rely on it
- You guess a diagnosis.
- You share a relative's details with an employer or a school.
- Living relatives are named with details they asked you not to spread.
This is not a custody order, a divorce paper, or a school district's required form. A permission letter helps when a camp, a school, or an airline accepts a parent letter. If they hand you their slip, use it. A parenting schedule is enforceable when a court enters it or both parents sign the form the court accepts, not when it is only printed.
How to fill and print it
- Fill the lines. Type into the Family Medical History in this browser. Write "not applicable" on a line that does not apply. What you type stays in this tab and is not uploaded.
- Check the preview. The boxed preview is the page that prints. Read it once as the person who will receive the paper.
- Print or download. Use Print, or download a filled PDF or a blank PDF. The file is built on your device.
More Family and children forms
Questions
What is a Family Medical History used for?
A family medical history is a private list of conditions in parents, siblings, and grandparents that a new doctor often asks about.
Who should use this Family Medical History?
It is for an adult collecting family history for a medical visit. Use it when before a new-patient appointment, from what relatives have actually told you.
Does this Family Medical History need a notary?
No. This Family Medical History has no notary block. Sign the Signature, Date line in ink on the printed page if you are handing it to someone.
Will a Family Medical History from Papero be accepted?
You guess a diagnosis. This is not a custody order, a divorce paper, or a school district's required form. A permission letter helps when a camp, a school, or an airline accepts a parent letter. If they hand you their slip, use it. A parenting schedule is enforceable when a court enters it or both parents sign the form the court accepts, not when it is only printed.
What gets a Family Medical History sent back?
You guess a diagnosis. You share a relative's details with an employer or a school. Living relatives are named with details they asked you not to spread.