Family Medical History

U.S. Department of State

Office of Medical Services

As part of your health care, you may be asked for Family Medical History. Providing this information is strictly voluntary and will only be used for diagnosis and treatment, and only by medical providers in MED. Medical Clearance decisions do not take into account Family Medical History, but only manifest diseases and medical conditions.

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Signature of patient (or parent of a minor child) Date

To be included in each patient's Medical Record

Doc#	Date	Version	Author	Clear	Revision Reason
3006	11/30/09	0	BAT	BAT	Original
3007.2	2/04/10	1	BAT	BAT	DCN Changed