This is the second part of your history. Provide your family history below and we'll add on to it at your appointment. Only mark the checkboxes if it is a yes.
When you have finished this section, you will be prompted to go on to the
next section. Remember, you can do it another time if you like, just go to http://onecircle.health/history.

Privacy is important, and these forms aren’t highly secured, so
do not put your full name in! Rather, only enter your initials and the date of your upcoming visit. This way, the only people who would be able to connect the submitted information to you is us and you.

(’60' or '97 of heart attack')

(remember to list the reasons for medications she takes/took)

(’60' or '97 of heart attack')

(remember to list the reasons for medications he takes/took)

(leave blank if no siblings, you can write 'doing well' if no health problems)

(enter ‘none' if you have no kids)

(leave blank if no kids, you can write 'doing well' if no health problems)

Please list from most to least

Alert!

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