Your Name________________________________
Date________________
FAMILY HISTORY QUESTIONNAIRE
INSTRUCTIONS: Answer as many of the following questions as you can. If you have documents that confirm your
answers (i.e.) birth, marriage or death certificates, etc., check the box that follows the question. Please Print.
1. What is your father's full name? ____________________________________________________________________________
2. When was your father born? _______________________________________________________________________________
3. Where was your father born?
(Town/City)____________________(County/Parish)____________________(State/Country)______
(If foreign born, indicate when and where he entered the U.S.) When:_______________ Where:________________
4. In what other places has your father lived? ___________________________________________________________________
5. If your father is deceased, when and where did his death occur?
When:___________________ Where:________________
6. What is your mother's full maiden name?
____________________________________________________________________
7. When was your mother born? ______________________________________________________________________________
8. Where was your mother born?
(Town/City)___________________(County/Parish)____________________(State/Country)______
(If foreign born, indicate when and where she entered the U.S.) When:_______________ Where: ________________
9. In what other places has your mother lived? ___________________________________________________________________
10. If your mother is deceased, when and where did her death occur?
When:__________________ Where:________________
11. When and where did the union of your parents occur?
When:___________________________ Where: ________________
12. If either had other spouses, indicate: His other Spouse: ____________________ Her other Spouse:_______________________
(If applicable: Date and place of other marriage/union: Date: __________ Place: ______________________________
CONCERNING YOUR PATERNAL GRANDPARENTS (Your father's parents)
13. What is your grandfather's full name? _______________________________________________________________________
14. When was your grandfather born? __________________________________________________________________________
15. Where was your grandfather born?
(Town/City)_________________(County/Parish)__________________(State/Country)______
(If foreign born, indicate when and where he entered the U.S.) When:__________________ Where:_______________
16. In what other places has your grandfather lived? _______________________________________________________________
17. If your grandfather is deceased, when and where did his death occur?
When:________________ Where:_______________
18. What is your grandmother's full maiden name?
_______________________________________________________________
19. When was your grandmother born? _________________________________________________________________________
20 Where was your grandmother born?
(Town/City)_________________(County/Parish)_________________(State/Country)______
(If foreign born, indicate when and where she entered the U.S.) When:_______________
Where: _______________
21. In what other places has your grandmother lived? _____________________________________________________
22. If your grandmother is deceased, when and where did her death occur?
When:______________ Where:______________
23. When and where did the union of your grandparents occur?
When:_______________________ Where: _____________
24. If either had other spouses, indicate: His other Spouse: ____________________ Her other Spouse:_______________________
(If applicable: Date and place of other marriage/union Date: ___________ Place: ______________________________
CONCERNING YOUR MATERNAL GRANDPARENTS (Your mother's parents)
25. What is your grandfather's full name? _______________________________________________________________________
26. When was your grandfather born? __________________________________________________________________________
27. Where was your grandfather born?
(Town/City)_________________(County/Parish)__________________(State/Country)______
(If foreign born, indicate when and where he entered the U.S.) When:_______________
Where:________________
28. In what other places has your grandfather lived? _______________________________________________________________
29. If your grandfather is deceased, when and where did his death occur?
When:_______________ Where:______________
30. What is your grandmother's full maiden name?
_______________________________________________________________
31. When was your grandmother born? _________________________________________________________________________
32. Where was your grandmother born?
(Town/City)_________________(County/Parish)_________________(State/Country)______
(If foreign born, indicate when and where she entered the U.S.) When:_______________ Where: ________________
33. In what other places has your grandmother lived? _____________________________________________________
34. If your grandmother is deceased, when and where did her death occur?
When:_____________ Where:______________
35. When and where did the union of your grandparents occur?
When:______________________ Where: _____________
36. If either had other spouses, indicate: His other Spouse: ____________________ Her other Spouse:_______________________
(If applicable: Date and place of other marriage/union Date: ___________ Place: ______________________________
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NAME____________________________________________
CONCERNING SIBLINGS - List the NAMES of the following; include their DATES and PLACES of BIRTH:
(List names in birth order. For siblings that are living, indicate “Private” next to their names.
Your brothers and sisters
1. ____________________________________________________2.__________________________________________________
3. ____________________________________________________4.__________________________________________________
5. ____________________________________________________6.__________________________________________________
7.____________________________________________________ 8.__________________________________________________
9. ____________________________________________________10._________________________________________________
Your father's brothers and sisters:
1. ____________________________________________________2.__________________________________________________
3. ____________________________________________________4.__________________________________________________
5. ____________________________________________________6.__________________________________________________
7.____________________________________________________ 8.__________________________________________________
9. ____________________________________________________10._________________________________________________
Your mother's brothers and sisters:
1. ____________________________________________________2.__________________________________________________
3. ____________________________________________________4.__________________________________________________
5. ____________________________________________________6.__________________________________________________
7.____________________________________________________ 8.__________________________________________________
9. ____________________________________________________10._________________________________________________
Your paternal grandfather's brothers and sisters:
1. ____________________________________________________2.__________________________________________________
3. ____________________________________________________4.__________________________________________________
5. ____________________________________________________6.__________________________________________________
7.____________________________________________________ 8.__________________________________________________
9. ____________________________________________________10._________________________________________________
Your paternal grandmother's brothers and sisters:
1. ____________________________________________________2.__________________________________________________
3. ____________________________________________________4.__________________________________________________
5. ____________________________________________________6.__________________________________________________
7.____________________________________________________ 8.__________________________________________________
9. ____________________________________________________10._________________________________________________
Your maternal grandfather's brothers and sisters:
1. ____________________________________________________2.__________________________________________________
3. ____________________________________________________4.__________________________________________________
5. ____________________________________________________6.__________________________________________________
7.____________________________________________________ 8.__________________________________________________
9. ____________________________________________________10._________________________________________________
Your maternal grandmother's brothers and sisters:
1. ____________________________________________________2.__________________________________________________
3. ____________________________________________________4.__________________________________________________
5. ____________________________________________________6.__________________________________________________
7.____________________________________________________ 8.__________________________________________________
9. ____________________________________________________10._________________________________________________
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Pmc.FHQ (Rev. 21 Sep 1999