CANCER FAMILY HISTORY QUESTIONNAIRE (updated 3/19)

Please correct the errors described below.

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.

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

Which Family Member(s)

Which Family Member(s)

Which Family Member(s)

Which Family Member(s)

Which Family Member(s)

Which Family Member(s)

Which Family Member(s)

Colon and Endometrial (Uterine) Cancer Family History

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.

Office Use Only:

BREAST CANCER RISK MODEL INFORMATION:

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.

Female Relatives Information

Your information will be encrypted.

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