FAMILY HISTORY QUESTIONNAIRE

Transcription

1 You have been referred for genetic counseling evaluation due to your personal and/or family history of cancer. In order to provide you with an accurate cancer risk assessment, it is important that we have as much information as possible regarding the cancers in your family. This information will help us to determine whether genetic testing will help you and/or other family members learn more about your risk for cancer. Please complete this questionnaire as thoroughly as possible. In some cases, it may be helpful to get additional information as well as genetic testing and pathology results from your family members. When you have completed this questionnaire, please fax it to (503) or mail it to us at Kaiser Permanente, Department of edical s, West Interstate edical Office, 3325 N Interstate Ave, Portland, OR Please feel free to contact us with any questions or concerns - phone or ext AILY HISTORY QUESTIONNAIRE Your name: Health Record Number: Date of Birth: : emale ale Address: Phone: Home: Cell: Work: To preserve your privacy, please tell us how we may contact you: Home phone: Yes No Cell phone: Yes No Work phone: Yes No ail: Yes No kp.org: Yes No Because some conditions occur more frequently in certain ethnic groups, please complete the following: Ancestry/race (check as many as apply): White/Caucasian Hispanic/Latina/Latino Black/African American Asian/Asian-American Native American/Alaskan Native Other: you know, please list the specific countries of origin of your ancestors: other s side: ather s side: Do you have family members of Ashkenazi Jewish descent? Yes, mother s side Yes, father s side No Unsure P 1 of 8

2 YOUR EDICAL HISTORY: Have you ever had a colonoscopy or sigmoidoscopy? Yes No yes: Approximate date of most recent colonoscopy or sigmoidoscopy: Where was it performed (Kaiser Permanente or other hospital?) How many polyps have been detected in total? How old were you when the first polyp(s) were found? Do you have any history of Yes, in the past Yes, ly No, never yes: How many years have/did you smoke? Approximately how many per day? Women only: How old were you when you had your first menstrual period? Are you still having menstrual periods? Yes No no, how old were you when you stopped having periods? Have you ever given birth? Yes No yes, how old were you when your first child was born? Have you ever taken birth control pills? Yes, in the past Yes, ly No, never yes, for how many years in total? Have you ever taken hormone replacement therapy? Yes, in the past Yes, ly yes: How many years in total? What type? estrogen only estrogen+progresterone combined Unsure Have you ever had a breast biopsy? Yes No yes: What (s)? Did you have atypical hyperplasia? Yes No Unsure Did you have lobular neoplasia? Yes No Unsure No, never How old were you when you had your first mammogram? What is the approximate date of your most recent mammogram? Have you ever had a breast RI? Yes No yes, what is the approximate date of your most recent breast RI? P 2 of 8

3 Have you had your uterus removed (hysterectomy)? Yes No Have you had both of your ovaries removed? Yes No P 3 of 8

4 INSTRUCTIONS OR COPLETING AILY HISTORY QUESTIONNAIRE 1. Please complete all of the information in the chart as well as possible. 2. List all requested BLOOD relatives, even if they do/did not have cancer. (Do NOT list people who have married into the family or who have been adopted into the family). Please attach additional ps if necessary. 3. you do not know an exact, please list an approximate. (Ex: 60s, 70s) 4. Write UNK (unknown) if you do not know or N/A (not applicable) if it does not apply. 5. or any relatives who have had genetic testing, please attach a copy of their test results if possible.* YOU amily ember ale or emale living, no history of cancer, write N/A testing?* 1. Your children Your grandchildren Please indicate which of your children is their parent P 3 of 8

5 amily ember Same mom? Yes or No Same dad? Yes or No living, no history of cancer, write N/A testing?* Your sisters Your brothers Your nieces and nephews Please indicate which of your brothers or sisters is their parent P 4 of 8

6 YOUR OTHER S AILY amily ember Your mother ale or emale living, no history of cancer, write N/A Testing?* Your mother s mother Your mother s father Your mother s sisters Your mother s brothers 1. Your first cousins on your mother s side who have had cancer P 5 of 8

7 YOUR ATHER S AILY amily ember Your father ale or emale living, no history of cancer, write N/A Testing?* Your father s mother Your father s father Your father s sisters Your father s brothers 1. Your first cousins on your father s side who have had cancer P 6 of 8

8 ANY OTHER RELATIVES WHO HAVE HAD CANCER? (Ex: great aunts or uncles, 2 nd cousins) On your OTHER's side living, amily ale or ember emale no history of cancer, write N/A Testing?* On your ATHER s side amily ember ale or emale living, no history of cancer, write N/A Diagnosis Testing?* Thank you for completing the family history questionnaire! *Please provide copies of genetic test results, if possible, for any relatives who have had genetic testing. results are not included, your appointment may be delayed. Please fax this form to (503) or mail it to us at Kaiser Permanente, Department of edical s, West Interstate edical Office, 3325 N Interstate Ave, Portland, OR Please feel free to contact us with any questions or concerns - phone or ext P 7 of 8