Genetic Health Service New Zealand: Adult family history form

Completing this form online

The form needs to be completed in one sitting (you cannot save your work and come back to it).

Please phone us on 0508 364 436 if you cannot complete the form, or do not feel comfortable completing it.

You can read the CCDHB Privacy Policy here.

Complete a paper copy

If you prefer to complete a paper copy, please go to the Genetic Health Service New Zealand website, where you can download a form and print

 

Alternatively we can mail you a questionnaire if you do not have access to a printer - phone us on 0508 364 436 if you would like us to send you a paper copy.

Help completing the form

  • If you do not know the answer, please leave blank. You may find it helpful to talk to other family members / whanau who have more information, and then fill this information in.
  • You only need to fill in your partner’s details if you have had children together or are planning to.
  • If you are not sure of a date, either leave blank or write the approximate year (and write “approx”).
  • If you need more space, please use the box at the end of each section.

If you are having difficulty filling out this form, please complete as much as you are able to. We will discuss the details further at your appointment.

  • Your details

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  • Have you or any of your other relatives ever attended a genetic clinic in NZ or overseas? If yes, please indicate:

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  • Your partner's details

    You only need to fill in your partner’s details if you have had children together or are planning to.

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  • Family/whānau information

    * For your close relatives please fill out the names and general information for everyone.
    * If you are adopted and do not have information on your biological relatives, please write “adopted” beside your name and return the form to us.
    * If any of your relatives are half brothers or sisters, please write “half” and tell us which parent you share.
    * If some of your relatives are not related by blood (eg stepbrothers or stepsisters), please do not list them.
    * If anyone in your family has changed their name, please list both the previous name and the name change.

  • Your children - child 1

    Please indicate next to full name Male/Female and whether F/HM/HF as per Relationship Key above

    Please also list miscarriages and stillbirths

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  • Child 2

    Please indicate next to full name Male/Female and whether F/HM/HF as per Relationship Key above

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  • Child 3

    Please indicate next to full name Male/Female and whether F/HM/HF as per Relationship Key above

  • 0/500 Words

  • Additional children

  • 0/2000 Words

  • Your sisters - sister 1

    Please indicate next to full name whether F / HM / HF as per Relationship Key.

  • 0/500 Words

  • Sister 2

    Please indicate next to full name whether F / HM / HF as per Relationship Key

  • 0/500 Words

  • Additional sisters

  • 0/2000 Words

  • Your brothers - brother 1

    Please indicate next to full name whether F / HM / HF as per Relationship Key

  • 0/500 Words

  • Brother 2

    Please indicate next to full name whether F / HM / HF as per Relationship Key

  • 0/500 Words

  • Additional brothers

  • 0/2000 Words

  • Your mother

  • 0/500 Words

  • Your father

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  • Any other information

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  • Your mother's brother

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  • Your mother's sister

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  • Your father's brother

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  • Your father's sister

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  • Your mother's parents

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  • Your father's parents

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  • Any other information

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Last updated 4 November 2020.