Many families have a history of health conditions such as cancer, diabetes, or heart disease. If there is a history of a particular condition in your family, you may be at greater risk of developing the condition.
The Virginia Department of Health has developed the Family Health History Form to make it easy for you to collect and record your family’s health information. Simply download the form, print it out, and fill in the information. We encourage families to complete a Family Health History on each family member and to share the information with their family physician.
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Tiara Green, MSEd Preconception Health Coordinator
Virginia Department of Health
Division of Women’s and Infants’ Health
109 Governor Street, 8th Floor, Richmond, Virginia 23219
Phone: (804) 864-7769 FAX: (804) 864-7771