Your family history is important to your healthcare. This is a screening tool for the common features of hereditary cancers.
*NCCN 2019: Personal diagnosis of Breast cancer > 50, Personal diagnosis of Colon or Uterine cancer > 64, Personal or Family History of Pancreatic Cancer at any age. ASBS 3/19 Personal diagnosis of breast cancer at any age.
Mother/Father/Sister/Brother/Daughter/Son, Aunt/Uncle/Grandmother/Grandfather/Niece/Nephew, Cousins/Great-grandparents
Which Family Member(s)
CANCER RISK ASSESSMENT REVIEW: To be completed with your healthcare provider
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Office Use Only:
ONLY COMPLETE IF YOU ANSWERED ‘YES’ TO ANY OF THE QUESTIONS IN THE GRID ON THE PREVIOUS PAGE
IF YES, is patient a
*Peri-menopausal: time before menopause marked by irregular periods. Post-menopausal: permanent cessation of period for 12 months or longer.
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