CANCER GENETICS PROGRAM FAMILY HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: First Name
( ) Maiden / Family Name
Date Completed: Last Name Appoin...
CANCER GENETICS PROGRAM FAMILY HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: First Name
( ) Maiden / Family Name
Date Completed: Last Name Appointment Date:
Date of Birth:
eMPI (staff use):
Please choose which ethnic/racial background best describes you and your biological mother and father. (Check all that apply) Self Mother Father White or Caucasian Black or African American Hispanic Asian Bi-racial Native Hawaiian and Other Pacific Islander American Indian and Alaska Native Unknown
Countries of Origin (ex: England, Nigeria, Mexico, Taiwan) Maternal side: Paternal side: Are either of your parents of Ashkenazi (Eastern/Central European) Jewish descent? No Unknown Yes: Both Maternal only Paternal only
CANCER HISTORY Have you ever been diagnosed with any cancer? Age at Diagnosis
Yes
No
Unknown
Treatment (Check all that apply) Cancer Type
Surgery
Chemotherapy
Radiation
Comments:
Page 1
Patient’s Name:
Birth date:
Date Completed:
REPRODUCTIVE HISTORY (WOMEN ONLY) Height:
Weight:
Age at the time of your first menstrual cycle Do you still get your period?
No
How old were you when your periods stopped?
Yes, LMP: What caused your periods to stop: Natural menopause
Surgery
Medication
Radiation
Other, specify Have you ever taken birth control pills?
No
Yes, how many years?
Have you ever been on hormone replacement therapy?
No
Yes, what drug and for how long?
Have you ever been pregnant?
No
Age at first live birth Number of full-term births
Number of stillbirths
Number of miscarriage or elective abortions Have you ever had a breast biopsy?
No
Yes, when and how many? How many were normal? How many were:
Have you ever had a tubal ligation?
No
Yes, when?
Have you ever had your ovaries or uterus removed?
No
Yes, when?
DCIS
I had removed: Uterus
LCIS
Right ovary
Atypical hyperplasia
Left ovary
Reason
Page 2
Patient’s Name:
Birth date:
Date Completed:
SCREENING HISTORY
Last Test/Exam
How Often
Age Started
Please describe any abnormal results
Women Pap Test / Pelvic Mammogram Breast ultrasound and/or MRI CA-125 Ovarian ultrasound Sigmoidoscopy / Colonoscopy
Any polyps?
Pancreatic screening Clinical skin evaluation Other: Men PSA Blood Test Sigmoidoscopy / Colonoscopy
FAMILY HISTORY Please list ALL your relatives, even if they have never had cancer. YOUR BIOLOGICAL CHILDREN: Gender M/F
First and Last Name
Living? Y/N
Current Age / Age at Death
Cancer? Y/N
Cancer type(s)
Age at Diagnosis
YOUR PARENTS AND GRANDPARENTS: First and Last Name
Living? Y/N
Current Age / Age at Death
Cancer? Y/N
Cancer type(s)
Age at Diagnosis
Your Mother Your Father Your Mother’s Mother Your Mother’s Father Your Father’s Mother Your Father’s Father
Page 4
Patient’s Name:
Birth date:
Date Completed:
YOUR BROTHERS AND SISTERS (include full and half siblings) Gender M/F
First and Last Name
Living? Y/N
Current Age / Age at Death
Cancer? Y/N
Cancer type(s)
Age at Diagnosis
Number of Children If any have had cancer, please list type and age at diagnosis # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History:
Page 5
Patient’s Name:
Birth date:
Date Completed:
YOUR MOTHER’S BIOLOGICAL BROTHERS AND SISTERS – (YOUR MATERNAL AUNTS AND UNCLES) (include full and half siblings) Gender M/F
First and Last Name
Living? Y/N
Current Age / Age at Death
Cancer? Y/N
Cancer type(s)
Age at Diagnosis
Number of Children If any have had cancer, please list type and age at diagnosis # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History:
Page 6
Patient’s Name:
Birth date:
Date Completed:
YOUR FATHER’S BIOLOGICAL BROTHERS AND SISTERS – (YOUR PATERNAL AUNTS AND UNCLES) (include full and half siblings) Gender M/F
First and Last Name
Living? Y/N
Current Age / Age at Death
Cancer? Y/N
Cancer type(s)
Age at Diagnosis
Number of Children If any have had cancer, please list type and age at diagnosis # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History:
Page 7
Patient’s Name:
Birth date:
Date Completed:
OTHER RELATIVES WITH CANCER Gender M/F
First and Last Name
Living? Y/N
Current Age / Age at Death
Relation to You
Cancer type(s)
Age at Diagnosis
Number of Children If any have had cancer, please list type and age at diagnosis # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History: # of Sons: # of Daughters: Cancer History:
Page 8
Patient’s Name:
Birth date:
Date Completed:
HOW DID YOU HEAR ABOUT US? 1. How were you referred to our program? (Check all the apply) My doctor specifically recommended genetics consultation. I asked my doctor about genetics, genetic testing, and/or my family history. Then s/he referred me for a genetics consultation. Family member Friend Genetics program brochure or other printed material Website (list site) TV / radio / magazine advertisement about genetic testing Other, explain: 2. Please check the reason you are seeking a genetics consultation (Check all that apply) I am concerned about my risk for cancer I am concerned about my relatives’ risk for cancer To learn more about what I or my relatives can do to prevent (or catch early) a hereditary condition Other, explain:
