Take Charge of Your Health!

Family, Social and Occupational History Sheet:

A very important part of your history!

Family History

The family history is very important, not only in helping in diagnosis, but in making recommendations for preventive health care. The family history should focus on your parents and siblings. Family history of diabetes, high blood pressure, high cholesterol, heart disease, kidney disease, strokes or Cancer are extremely important to document.

List each family member and right down any significant health condition and approximate age. For example: "Father - heart attack age 47" or "Mother - diabetes - onset in her 50's."

These are some disease states that can run in families:
Alzheimer’s disease or dementia Arthritis Asthma Birth defects Cancer (breast, colon, lung, prostate, ovarian, and other cancers) Diabetes Depression Heart disease or sudden heart attack Other heart problems High blood pressure and high cholesterol Pregnancy losses, stillbirths, and miscarriages Stroke or blood clots

Social History

the social history is where you describe any social habits that could have either a negative or positive impact on your health. Smoking, alcohol consumption and caffeine may have negative impacts. Regular exercise, plant based diet, low fat and low sodium diet have positive impacts and should be listed. Illicit drug use or any high risk activities (IV drug use, tatoos, multiple sex partners) can be listed here as well.

Occupational History

The occupational history can be important in terms of job stress, degree of activity and exposure to toxic chemicals or other hazards. Examples include lung disease secondary to inhaled dusts, irritant gases or toxic fumes in a workplace.

Problem Sheet

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Medication Sheet

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Immunization Sheet

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Family History

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Social & Occupational
History

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Tracking Symptoms
Your Health Diary

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