Family History Questionnaire for Common Hereditary Cancer Syndromes
Please correct the errors described below.
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)
BREAST AND OVARIAN CANCER (BRCA)
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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)
Colon or Uterine Cancer (diagnosed <50) or dx at any age with another Lynch* cancer in person/family
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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