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.
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BRCA- Personal or Family History
One person with: (out to 2nd degree)
Two persons with: (out to 3rd degree)
Three Persons with: (out to 3rd degree)
Lynch*-
Personally affected:
Colon or Uterine Cancer (diagnosed <50) or dx at any age with another Lynch* cancer in person/family
Family History
*Colon, uterine/endometrial, stomach, ovarian, brain, kidney, small bowel
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