| Family History Questionnaire for Common Hereditary Syndromes | ||||||||||
| Patient Name: ____________________________ | Physician:___________________________ | |||||||||
| Date of Birth: ________________________ | Date Completed: ______________________ | |||||||||
| Instructions: Please circle Y to those that apply to YOU and/or YOUR FAMILY (on both your mothers or fathers side). Behind each statement | ||||||||||
| please list the relationship to your of the individual diagnosed (such as paternal uncle, maternal aunt, paternal grandmother) and their age at | ||||||||||
| diagnosis. Each statement should be answered individually, so you may list the same cancer diagnosis more that once as you answer these | ||||||||||
| questions. This is a screening tool for the common features of hereditary cancer syndromes. If you circle Y to any statement below you MAY be | ||||||||||
| appropriate for genetic testing. Ask your your healthcare provider if you have any questions or need additional information. | ||||||||||
| BREAST AND OVARIAN CANCER PERSONAL HISTORY | RELATIONSHIP | AGE AT DIAGNOSIS | ||||||||
| Y | N | Have you had breast cancer before age 50? | ___________________ | ________ | ||||||
| Y | N | Have you ever had ovarian cancer? | ___________________ | ________ | ||||||
| Y | N | Have you ever had breast cancer in both | ||||||||
| breasts or multiple primary breast cancers? | ___________________ | ________ | ||||||||
| Y | N | Have you ever had both Breast AND Ovarian Cancer? | ___________________ | ________ | ||||||
| FAMILY HISTORY | ||||||||||
| Y | N | Has anyone in your family ever had breast cancer | ||||||||
| or ovarian cancer (if yes, Who?) | ___________________ | ________ | ||||||||
| Y | N | Is there Male breast cancer in your family? | ___________________ | ________ | ||||||
| Y | N | Are you Ashkenazi Jewish ancestry? | ___________________ | ________ | ||||||
| If yes have your had breast/ovarian cancer? | ___________________ | ________ | ||||||||
| Or have any family members had breast/ovarian cancer? | ___________________ | ________ | ||||||||
| COLON AND UTERINE CANCER PERSONAL HISTORY | ||||||||||
| Y | N | Have you had Uterine Cancer before age 50? | ___________________ | ________ | ||||||
| Y | N | Have you had colorectal cancer before age 50? | ___________________ | ________ | ||||||
| Y | N | Have you ever had both Uterine AND Colorectal Cancer? | ___________________ | ________ | ||||||
| Y | N | Have you had ovarian, stomach, kidney/urinary tract, | ||||||||
| brain OR small bowel cancer? | ___________________ | ________ | ||||||||
| FAMILY HISTORY | ||||||||||
| Y | N | Has anyone in your family ever had Uterine cancer or | ||||||||
| Colorectal Cancer (if yes, who?) | ___________________ | _________ | ||||||||
| Y | N | Has anyone in your family had ovarian, stomach, | ||||||||
| kidney/urinary tract, brain OR small bowel cancer? | ________________ | ________ | ||||||||
| COLON POLYP HISTORY | ||||||||||
| Y | N | 10 or more colon polyps found in a lifetime | ________________ | ________ | ||||||
| _____ | Candidate for further risk assessment and/or genetic testing | _____ | Patient offered genetic testing | |||||||
| _____ | Information given to patient to review | _____ | Accepted | |||||||
| _____ | Follow up appointment: Scheduled Date: ___________________ | _____ | Not a candidate for testing | |||||||
| _____ | BRCA Test | _____ | Colaris/ Colaris AP | |||||||
| _________________________________________________________________________ | ||||||||||
| Patient Signature | Date | |||||||||
| _________________________________________________________________________ | ||||||||||
| Health Care Providers Signature | Date | |||||||||
Download Family History Questionnaire, click here.