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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

Appendix 2A. Family history screening questionnaire

The use of a simple family history screening questionnaire (FHSQ) can help identify individuals who may require a more detailed assessment of their family history of cancer, heart disease or diabetes.1

This tool can be used as part of the patient’s assessment at their first visit to a practice. If patients are uncertain about their family history, they can be asked to discuss the FHSQ with their relatives prior to completing the questionnaire. For patients with low literacy, the FHSQ may need to be completed with the support of a healthcare professional.

A positive response to any question requires follow-up with a more detailed assessment of the family history. As family history can change it is recommended that the FHSQ be repeated at least every three years.

This risk assessment focuses on your close relatives including parents, children, brothers and sisters who are either living or dead.
QuestionYesNo
Have any of your close relatives had heart disease before 60 years of age?

Heart disease includes cardiovascular disease, heart attack, angina and bypass surgery.
Have any of your close relatives had diabetes?

Diabetes is also known as type 2 diabetes or non-insulin dependent diabetes.
Do you have any close relatives who had melanoma?
Have any of your close relatives had bowel cancer before 55 years of age?
Do you have more than one relative on the same side of the family who had bowel cancer at any age?

Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren.*
Have any of your close male relatives had prostate cancer before 60 years of age?
Have any of your close female relatives had ovarian cancer?
Have any of your close relatives had breast cancer before 50 years of age?
Do you have more than one relative on the same side of your family who has had breast cancer at any age?

Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren.*
*Only first-degree and second-degree relatives need be considered in this screening questionnaire.

Reproduced with permission from Emery JD, Reid G, Prevost AT, Ravine D, Walter FM. Development and validation of a family history screening questionnaire in Australian primary care. Ann Fam Med 2014;12(3):241–49.

References

  1. Emery JD, Reid G, Prevost AT, Ravine D, Walter FM. Development and validation of a family history screening questionnaire in Australian primary care. Ann Fam Med 2014;12(3):241–49.
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