Family History Questionnaire for Common Hereditary Cancer Syndromes

Patient Name

Date

Age

Height

Weight

Age of First Period

Age of First Child (if applicable)

Are You Menopausal

Yes No

Have you ever used Hormone Replacement Therapy?

Yes No

Has anyone in your family had genetic testing for a hereditary cancer syndrome?

Yes No

Please mark below if there is a personal or family history of any of the following cancers. If yes, then indicate family relationship AND age at diagnosis in the appropriate column. Consider parents, children, brothers, sisters, grandparents, aunts, uncles, and cousins.

COLON AND UTERINE CANCER (Colaris)

Uterine (endometrial) cancer

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Colon cancer

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Ovarian, stomach, kidney/urinary tract, brain OR small bowel cancer

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

10 or more colon polyps found in a lifetime

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

BREAST AND OVARIAN CANCER (BRCA)

Breast cancer

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Breast cancer in both breasts OR multiple primary breast cancers

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Ovarian cancer

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Male breast cancer

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Are you of Ashkenazi Jewish descent?

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

OTHER CANCERS

Prostate Cancer (BRCA)

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Pancreatic Cancer (Col/BRCA)

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

Melanoma (BRCA)

Y N

You (age of diagnosis)

Siblings / Children (age of diagnosis)

Mother’s Side (age of diagnosis)

Father’s Side (age of diagnosis)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

For Office Use Only:

Patient meets NCCN criteria for testing

Yes No

IF Yes, HBOC or Lynch

HBOC Lynch

Follow-up appointment scheduled

Yes No

Date of Appointment

Patient offered hereditary cancer testing?

Yes No

If YES

ACCEPTED DECLINED

Health Care Provider’s Signature

Date

BRCA- Personal or Family History

One person with: (out to 2nd degree)

Breast (diagnosed ≤45)
Ovarian any age
Male breast any age
Breast with Ashkenazi Jewish heritage any age
Bilateral breast (diagnosed ≤50)
Triple negative breast (diagnosed ≤60)

Two persons with: (out to 3rd degree)

Breast Cancer age (2 diagnosed ≤50)
Breast Cancer & Ovarian Cancer (any age)

Three Persons with: (out to 3rd degree)

Breast and/or pancreatic and/or ovarian (any age)

Lynch*-

Personally affected:

Colon or Uterine Cancer (diagnosed <50) or dx at any age with another Lynch* cancer in person/family

Family History

A 1st degree relative w/ CRC or Uterine cancer <50
Two 1st/ 2nd degree relatives w/ Lynch tumor, any age

*Colon, uterine/endometrial, stomach, ovarian, brain, kidney, small bowel

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