CANCER FAMILY HISTORY QUESTIONNAIRE (updated 3/19)

Your family history is important to your healthcare. This is a screening tool for the common features of hereditary cancers.

Patient Name

Date of Birth

Gender

Male Female

Today’s Date

Address

Patient Ethnicity

White/Non-Hispanic

Hispanic/Latino

Black/African

Ashkenazi Jewish

Asian

Native American

Pacific Islander

Middle Eastern

Other

If other, please specify.

Are you of Ashkenazi Jewish ancestry?

Yes No

Have YOU ever had BREAST, OVARIAN, COLON, UTERINE (Endometrial), Pancreatic, or Metastatic Prostate Cancer:

Yes No

Cancer

*Age of diagnosis

*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.

Please include the following family members:

Mother/Father/Sister/Brother/Daughter/Son, Aunt/Uncle/Grandmother/Grandfather/Niece/Nephew, Cousins/Great-grandparents

Breast and Ovarian Cancer Family History

Family member who had breast cancer BEFORE AGE 50

Y N

Which Family Member(s)

Mom’s Family

Dad’s Family

Age of Cancer

Family member who had ovarian or pancreatic cancer AT ANY AGE

Y N

Which Family Member(s)

Mom’s Family

Dad’s Family

Age of Cancer

Three family members, ON THE SAME SIDE of the family, who had breast, pancreatic, or prostate cancer AT ANY AGE

Y N

Which Family Member(s)

Mom’s Family

Dad’s Family

Age of Cancer

Family member who had triple negative breast cancer before age 60 (ER, PR, and HER2 negative receptor status)

Y N

Which Family Member(s)

Mom’s Family

Dad’s Family

Age of Cancer

One family member who had multiple breast cancers (in the same breast OR both breasts)

Y N

Which Family Member(s)

Mom’s Family

Dad’s Family

Age of Cancer

Family member who had MALE BREAST CANCER AT ANY AGE

Y N

Which Family Member(s)

Mom’s Family

Dad’s Family

Age of Cancer

Family member who had metastatic prostate cancer AT ANY AGE

Y N

Which Family Member(s)

Mom’s Family

Dad’s Family

Age of Cancer

Colon and Endometrial (Uterine) Cancer Family History

Family member who had uterine cancer BEFORE AGE 50

Y N

Mom’s Family Cancer

Dad’s Family Cancer

Age of Cancer

Family member who had colon or rectal cancer BEFORE AGE 50

Y N

Mom’s Family Cancer

Dad’s Family Cancer

Age of Cancer

Three family members, ON THE SAME SIDE, who have had colon/rectal or uterine cancer AT ANY AGE

Y N

Mom’s Family Cancer

Dad’s Family Cancer

Age of Cancer

Any family members with the following cancers?

Y N

Check

stomach

small bowel

brain

pancreas

kidney/urinary tract

ureter or renal pelvis

Mom’s Family Cancer

Dad’s Family Cancer

Age of Cancer

PLEASE TURNOVER AND COMPLETE THE BACK ONLY IF YOU ANSWERED ‘YES’ TO ANY OF THE ABOVE QUESTIONS ON THE GRID.

CANCER RISK ASSESSMENT REVIEW: To be completed with your healthcare provider

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

Healthcare Provider Signature

Date

Office Use Only:

Patient appropriate for hereditary cancer genetic testing?

Yes No

Patient was offered genetic testing?

Accepted Declined

Follow-up appointment scheduled

Yes No

BREAST CANCER RISK MODEL INFORMATION:

ONLY COMPLETE IF YOU ANSWERED ‘YES’ TO ANY OF THE QUESTIONS IN THE GRID ON THE PREVIOUS PAGE

Height (ft./in)

Weight (lbs.)

How old were you when you got your first menstrual period

Are you

Pre-menopausal Peri-menopausal Post-menopausal

Age of onset

Have you had a live childbirth?

Yes No

How old were you at your first child’s birth

Have you ever used Hormone Replacement Therapy?

Yes No

IF YES, Treatment Type

Combined

Estrogen Only

Progesterone Only

IF YES, is patient a

Current User

Started

Intended use for

Past User

Stopped

Have you had breast biopsy?

Yes No

IF YES, Did it show

No Benign Disease

Hyperplasia

Atypical Hyperplasia

LCIS

Biopsy

Result Unknown

*Peri-menopausal: time before menopause marked by irregular periods. Post-menopausal: permanent cessation of period for 12 months or longer.

Female Relatives Information

How many daughters do you have?

How many sisters do you have?

How many sisters does your mother have?

How many sisters does your father have?

Your information will be encrypted.