Family History Screening Questionnaire (FHSQ)

Family History Screening Questionnaire (FHSQ) Key: (+) yes, (-) no, (?) unsure PART 1 - First degree relatives (parents, children, brothers and sisters; either living or dead) History of: (-) Heart disease < 60 years of age. "Heart disease" includes cardiovascular disease, heart attack, angina and bypass surgery. (-) Diabetes - type 1 or 2. (-) Melanoma. (-) Bowel cancer < 55 years of age. (-) More than one relative on the same side of the family with bowel cancer at any age. Comments: PART 2 - First and second degree relatives (parents, children, brothers, sisters, grandparents, aunts, uncles, nieces, nephews and grandchildren) History of: (-) Prostate cancer < 60 years of age. (-) Ovarian cancer. (-) Breast cancer < 50 years of age. (-) More than one relative on the same side of the family with breast cancer at any age. (-) Sudden cardiac arrest (SCA) or sudden cardiac death (SCD) < 45 years of age. (-) Family history of known genetic conditions (specify condition/relationship). Comments:

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A positive response to any question requires follow-up with a more detailed assessment of the family history. As family history can change over time, the FHSQ should be repeated at least every three years. Only first-degree and second-degree relatives need be considered in this screening questionnaire.

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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. [Available at https://www.annfammed.org/content/12/3/241.long]