Family History Questionnaire
What is the Family History Questionnaire?
The Family History Questionnaire is a comprehensive form in Wingspan's Family History feature that asks if a particular family member (mother, father, maternal grandmother, maternal grandfather, paternal grandmother, and paternal grandfather) has a condition(s) among a list.
Demo of taking the Family History Questionnaire in Wingspan.
How to Take the Family History Questionnaire in Wingspan Health
Step-by-Step Guide:
Log into your Wingspan account
Click the Family History block on the Dashboard OR click on Family History in the menu on the left.
Click on a block in the Family History Tree to fill out the questionnaire for a family member OR click the Ask a Family Member button to send the questionnaire for a family member to fill out.
You will be shown a list of conditions for a particular health category and will have to check off the ones that your particular family member has. If you do not see their condition listed, you can always add it under Other by specifying.
When you reached the end of the questionnaire, hit the Submit button!
Family History Questionnaire Sections
Continue reading below to see all of the questions asked in the Family History Questionnaire.
Click a link in the list below to jump to a section:
Allergies
In the Allergies section, you will be shown a list of allergies that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any food or non-food allergies?
Yes
No
Select all that apply for your family member.
Aspirin
Dairy
Eggs
Fish
Latex
NSAIDs (ibuprofen & naproxen)
Peanuts
Penicillin
Red Meat
Seasonal (trees, pollen)
Shellfish
Soy
Sulfa Drugs
Tree Nuts (almond, cashew, etc)
Wheat
Other
Blood Pressure
In the Blood Pressure section, you will be asked whether your family member has had high blood pressure?
Has your family member had high blood pressure? If they’re on medication for high blood pressure, select Yes.
Yes
No
Cancer
In the Cancer section, you will be shown a list of types of cancer that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any type of cancer?
Yes
No
What type of cancer has your family member experienced?
Bladder Cancer
Breast Cancer
Colon Cancer
Endometrical Cancer
Kidney Cancer
Leukemia
Liver or Bile Duct Cancer
Lung Cancer
Melanoma
Non-Hodgkins Lymphoma
Ovarian Cancer
Pancreatic Cancer
Prostate Cancer
Skin Cancer, non-melanoma
Testicular Cancer
Thyroid Cancer
Other
Cardiovascular
In the Cardiovascular section, you will be shown a list of cardiovascular issues that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any cardiovascular issues, including anemia, irregular heartbeat, or heart disease?
Yes
No
Select all cardiovascular issues your mother has experienced.
Abdominal Aortic Aneurysm
Aneurysm, Other
Iron Deficiency (anemia)
Congenital Heart Disease (hole, malformation)
Deep Vein Thrombosis (DVT)
Heart Attack
Hemophilia or Bleeding Disorder
Irregular Heartbeat (arrhythmia)
Pulmonary Embolism
Stroke
Sickle Cell Anemia
Other
Cholesterol
In the Cholesterol section, you will be asked if your family member has high cholesterol.
Has your family member had high cholesterol? If they’re on medication for high cholesterol, select Yes.
Yes
No
Connective Tissue
In the Connective Tissues section, you will be shown a list of conditions related to connective tissue that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any history of connective tissue disorders (arthritis, lupus, gout, etc)?
Yes
No
Select all that apply for your family member.
Ankylosing Spondylitis
Ehlers Danlos Syndrome
Gout
Juvenile Arthritis (JA)
Lupus
Osteoarthritis (OA)
Psoriatic Arthritis
Rheumatoid Arthritis (RA)
Scleroderma
Other
Diabetes
In the Diabetes section, you will be shown a list of types of diabetes that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Your family member has had
Type 1 Diabetes (childhood onset)
Type 2 Diabetes (adult onset)
Mature Onset Diabetes of the Young (MODY)
Gestational Diabetes
Other
Digestive
In the Digestive section, you will be shown a list of digestive conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any digestive system issues? (includes appendix, liver, digestive tract)
Yes
No
Select all digestive conditions that apply for your family member.
Celiac Disease
Colon Polyps
Crohn’s Disease
Gastroparesis
GERD (Gastroesophageal Reflux Disease)
Irritable Bowel Syndrome
Peptic Ulcer Disease
Ulcerative Colitis
Other
Hearing
In the Hearing section, you will be shown a list of hearing conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your mother had any hearing or ear issues?
Yes
No
Select all hearing or ear issues your family member has experienced.
Auditory Processing Disorder
Adult Hearing Loss (age 40+)
Hearing Loss - Other
Deafness
Other
Internal Organs
In the Internal Organs section, you will be shown a list of issues with internal organs that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any issues with other internal organs (kidney, liver, appendix, etc.)?
Yes
No
Select all that apply for your father.
Appendicitis
Gallstones
Gallbladder Disease, Other
Kidney Stones
Kidney Disease, Other
Liver Disease, Other
Pancreatitis
Other
Mental Health
In the Mental Health section, you will be shown a list of mental health conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any history of mental health conditions, including anxiety or addiction?
Yes
No
Select all that apply for your family member.
Addiction (Drugs, Alcohol, etc)
Anxiety
Autism Spectrum Disorder
Bipolar Disorder
Depression
Eating Disorder
OCD (Obsessive Compulsive Disorder)
Personality Disorder (Borderline, Antisocial, etc)
Psychosis
PTSD (Post Traumatic Stress Disorder)
Schizophrenia
Other
Neurological
In the Neurological section, you will be shown a list of neurological conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any neurological conditions, including migraines, seizures, or cognitive decline?
Yes
No
Select all neurological conditions your family member has experienced.
ALS (Amyotrophic Lateral Sclerosis)
Alzheimer’s
Autoimmune Encephalitis
Bells Palsy
Brain Tumor
Cerebral Aneurysm
Dementia
Epilepsy
Migraines
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Parkinson’s Disease
Neuromuscular Disease, Other
Seizures, Non-Epileptic
Other
Reproductive
In the Reproductive section, you will be shown a list of reproductive conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any reproductive issues, including chronic UTIs, PCOS, or infertility?
Yes
No
Select all that apply for your family member.
Chronic UTIs
Endometriosis
Erectile Dysfunction
Early Menopause
Infertility
Late Stage Pregnancy Loss
PCOS (Polycystic Ovarian Syndrome)
Repeat Pregnancy Loss
Other
Respiratory
In the Respiratory section, you will be shown a list of respiratory conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any chronic respiratory conditions?
Yes
No
Select all that apply for your mother.
Asthma
COPD / Emphysema
Cystic Fibrosis
Other
Skin
In the Skin section, you will be shown a list of skin conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any history of medically treated skin conditions (acne, eczema, etc)?
Yes
No
Select all that apply for your family member.
Acne
Eczema
Hidradenitis Suppurativa (HS)
Psoriasis / Psoriatic Arthritis
Rosacea
Shingles
Vitiligo
Other
Vision
In the Vision section, you will be shown a list of vision or eye conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying.
Has your family member had any vision or eye issues (including glasses)?
Yes
No
Select all eye issues your family member has experienced.
Glasses before age 40
Glaucoma
Age-Related Macular Degeneration (AMD)
Cataracts
Diabetic Retinopathy
Lazy Eye (Amblyopia)
Crossed Eyes (Strabismus)
Color Blindness
Blindness
Other
Other
In the Other section, you will be shown a list of other conditions that your family member may or may not have. Check the ones that they have and if you don't see one that they have listed, you can always add it under Other by specifying. If none of the listed conditions apply, select None.
Has your family member had any of these other conditions?
Anesthesia - Unexpected Response
Cerebral Palsy
Congenital Malformation, Any
Down Syndrome
Fabry Disease
Graves’ Disease
Huntington’s Disease
Marfan Syndrome
Spinal Muscular Atrophy (SMA)
Thalassemia
None
Other
About Wingspan Health
Wingspan Health is a healthcare technology company that believes that quality healthcare should be accessible for everyone.
Our tool helps you understand your health by organizing your medical information in one place – from all of your patient portal accounts at each of your healthcare providers.
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