HEREDITARY CANCER FAMILY HISTORY QUESTIONNAIRE
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1 Packet received: Appointment: HEREDITARY CANCER FAMILY HISTORY QUESTIONNAIRE Please complete this questionnaire. While this can take some time, a review of your family history will allow us to provide you with a cancer risk assessment and to determine whether genetic testing would aid in cancer risk assessment for you and/or other family members. Please return this questionnaire (via mail or fax) so that we can schedule your appointment. If you have questions or need to speak to a Genetic Counselor, please call Mailing/Clinic Address: Shodair Children s Hospital Department of Medical Genetics 2755 Colonial Drive Helena, MT Fax: PLEASE NOTE: If one of your close relatives has already had genetic counseling for cancer risk assessment and/or genetic testing, you may not need to complete this entire questionnaire. Instead, send us the following: 1. Pages 1-3 of this questionnaire 2. Copy of the family tree, consultation summary, and genetic test results on your relative INSTRUCTIONS FOR COMPLETING THE FAMILY HISTORY QUESTIONNAIRE: Please fill in all of the columns as completely as possible. Please record ALL relatives, EVEN IF THEY DO/DID NOT HAVE CANCER. If you have no relatives in any of the categories listed, please put an X in the box for NONE. Please give as much information as possible about dates of birth and or current ages/ages at. Approximate ages are okay (ex: 70s). Write UNK (unknown) if you do not know, or NA (not applicable) if information requested does not apply. 1 P a g e R e v. 0 1 /
2 PERSONAL INFORMATION Your name: Address: Date of Birth: Your gender: Male _Female Telephone: Home: Work: Cell: _ To preserve your privacy, please tell us may we contact you By phone at home? Yes No By cell phone? Yes No By phone at work? Yes No By mail? Yes No By ? (if yes, enter here) Ancestry/race (check as many as apply) White/Caucasian Hispanic/Latina/Latino Black/African American Asian/Asian-American American Indian/Alaskan Native Multiracial (specify) Other (specify) If you know, please list the specific countries where your distant ancestors originated. Mother s side: Father s side: Because some health conditions occur more frequently in Jewish populations, please answer: Is your father Ashkenazi Jewish? Yes No Unsure Is your mother Ashkenazi Jewish? Yes No Unsure 2 P a g e R e v. 0 1 /
3 LIFESTYLE AND SOCIAL HISTORY Do you smoke? Yes No If yes, how many cigarettes per day? Do you drink alcohol? Yes No If yes, how many drinks per week? What do you do for a living? _ Have you ever been exposed to large amounts of chemicals? If so, what and when? TO AID IN CANCER RISK ASSESSMENT: Number of colonoscopies or sigmoidocopies you have had? Women only: Were any polyps detected? If so, how many polyps were detected? If so, age that polyps were detected? at your first menstrual period Number of breast biopsies you have had Have any biopsies revealed atypical hyperplasia? Have any biopsies revealed lobular neoplasia? If so, age at diagnosis of lobular neoplasia at first childbirth Yes No Unsure Yes No Unsure Yes No Unsure Have you had your uterus removed? (hysterectomy) Yes No Have you had your ovaries removed? Yes No 3 P a g e R e v. 0 1 /
4 PLEASE LIST EVERY RELATIVE REQUESTED Please write UNK if you don t know or can t get the answer. Please write NA if the column doesn t apply. Thank you. IMMEDIATE FAMILY Family You Spouse / partner Children (if your children have different parents please write the parent's name in None Your mother Your father Your brothers and sisters (if they are half siblings please indicate the shared parent in None Type of / 4 P a g e R e v. 0 1 /
5 Family nieces and nephews your brother or sister who is the parent in None grandchildren your child, who is the parent in None Type of / 5 P a g e R e v. 0 1 /
6 FATHER S SIDE OF FAMILY Family grandmother grandfather your aunts and uncles (father's siblings) your cousins your aunt or uncle, who is the parent in None None Type of / 6 P a g e R e v. 0 1 /
7 MOTHER S SIDE OF FAMILY Family grandmother grandfather your aunts and uncles (mother's siblings) your cousins your aunt or uncle, who is the parent in None None Type of / 7 P a g e R e v. 0 1 /
FAMILY HISTORY QUESTIONNAIRE
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