Revised 10-04-2011

IRB 097-092

Hereditary Cancer Risk Program

Family History and Risk Assessment Questionnaire

Please answer questions to the best of your ability in order to help us establish your risk assessment. Write in “unk” (unknown) for information not known.

If you have any questions or if you need to schedule/change an appointment, please call 214-820-9600

Please send or fax this completed questionnaire

to us at least 1 week prior to your appointment

(page 2-7)

(Fax: 214-820-9606)

Patient Information

Name: ______

(Last) (First) (Middle)

Address: ______

(Street)

______

(City) (ST) (Zip)

Home Phone: ______Cell Phone: ______

Email address:______

Birth date: ______Age: ______Social Security No.:______

When is the best time to contact you? ______

May we email you if we need additional information? ______

Please tell us how to contact you: Work_____ Home _____ Email_____ Cell ______

Who referred you to the Hereditary Cancer Risk Program?

______

What is the reason you have been referred to the Hereditary Cancer Risk Program?

______

………………………………………………………………………………………………………

Office Use-

ID:______

Other family members in HCRP
Your background – All Participants
What is your race or ethnic background?
If you are multi-racial, check all that apply
Adopted / White Black Hispanic Asian E. Indian
French Canadian Mediterranean/Greek/Italian
Native American Indian Multiracial
Other:______
Ashkenazi Jewish descent
What country is your mother’s family from?
______
What country is your father’s family from?
______
What is the highest level of education you completed? / Elementary school Middle school High school
Some college College degree Graduate/Professional degree
What is your Occupation?
Your current height: ______/ Your current weight:______
Your Health History – All Participants
Colon Cancer Screening / Have you ever had a colonoscopy?
Yes, when:______
What were the results?______
______
No
Dermatological / Have you ever been told you have unusual skin findings (ex: lumps, bumps, lesions, light or dark spots)?
Yes, what:______
______
No
Have you had any exposures that could affect cancer risks? Yes No
(ex; radiation, chemical plants, work exposures, smoking)
Do you have any ongoing health problems?
Yes
No / Briefly describe any health problems here:
Your Health History – Female Participants only
Menstrual History / When did you begin your menstrual cycles?
______Years old
Have you gone through menopause?
Yes, age:______
No
Pregnancy History (if applicable) / How many times have you been pregnant?______
How many children have you had?______
How old were you when you had your first child?______
Have you ever taken birth control pills? / Yes No
If yes, for how long? ______years
Have you ever taken
hormone replacement therapy? / Yes No
If yes, how many years? ______Type______
At what age did you start?______
Have you had your Uterus removed? / Yes No
If yes, reason:
Have you had your ovaries removed? / Yes No
If yes: One ovary Both ovaries
If yes, reason:
Have you ever had a breast biopsy? / 0 Yes 0 No
If yes, how many have you had? #____
Result of last breast biopsy / 0 Invasive (lobular or ductal carcinoma)
0 In-situ (DCIS or LCIS)
0 Atypical hyperplasia (AH)
0 Other:______
0 Unknown
Biopsy History
Biopsy type: / Result:
Biopsy type: / Result:
Breast Cancer History (if applicable)
Cancer in which Breast?
Right
Left
Both
Age at diagnosis:
______/ Lumpectomy left_____ right ______
Mastectomy- left_____ right ______
Surgeon:______
Radiation therapy
Radiation Oncologist:______
Chemotherapy
Other treatment:______
Oncologist:______
Personal Cancer History (if applicable)
What type of cancer were you diagnosed with?
______
______
Age at diagnosis:_____ / What treatment did you have? ______
______
______
Physician(s):______
What type of cancer were you diagnosed with?
______
______
Age at diagnosis:_____ / What treatment did you have? ______
______
______
Physician(s):______

Family History

Please list all of your family Members that have been affected by Cancer

Name
(First name only okay)
M (male) or F (female) / Relationship
-Please Be Specific-
Examples:
Aunt – Mom’s side,
Great aunt –Dad’s father’s sister,
Cousin - Aunt Jennie’s daughter / Age
Now or
Age at Death
(N or D)
(ex: 55 N) / Location of cancer
(ex: breast, thyroid, colon, etc)
For breast, indicate if cancer is in both breasts (bilateral) / Age of cancer diagnosis
(Estimate)

Has anyone in your family tested positive for a mutation in a cancer gene?

Yes No if yes, what gene?______

(if yes, please bring a copy of your family member’s test result to your appointment)

Your Family Tree

Mother / Age:
(now or age deceased) / Father / Age:
(now or age deceased)
Total (Indicate half siblings) / Ages / Total (Indicate half siblings) / Ages
How many sisters do you have? / How many brothers do you have?
How many daughters do you have? / How many sons do you have?
How many maternal aunts do you have? / How many maternal uncles do you have?
How many paternal aunts do you have? / How many paternal uncles do you have?
Do you have any questions or concerns for the genetic counselor?

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