North East Thames Regional Genetic Service

Cancer Genetics Service

You have been referred to the Cancer Genetics Service because of a history of cancer in your family. We would be grateful if you would complete this questionnaire which will help us to assess whether or not your family history places you at an increased risk of cancer.

Please attempt to complete as many sections as possible. The more details you can provide, the more accurate we can be in our assessment. It is important to include those family members (alive and deceased) who have had, as well as those who have not had cancer, as this will affect your overall cancer risk. Please complete all pages and return them either by post or fax in advance of your appointment, preferably at least 2 weeks in advance (details at top of page). Please can you also make a copy and bring this to clinic with you, in case it does not reach us in time.If you have any queries or difficulties in completing the questionnaire, please do not hesitate to contact us at the above address. If you are unable to complete all the sections, please return the form anyway.

Title (Mr / Mrs / Miss etc)………………………..GP Name:………………………………………………..

FirstName: ……………………………. ………….GP Address:…………………………………………….

Surname: ……………………..………………………………………….………………………………………

Date of Birth: ……...…/…….….…/……..…....…………………………………………………………….

Address:……………………………………………GPTel No:……………………………………………….

……………………………………………………….

YourNHS No:…………………………………………..

Postcode:………………………………………….

Email:(optional)..……………………………………….

Mobile:……………………………………………..

Telephone/Home:……………………………………..

Yourself:

  • Occupation ………………………………Do you smoke? YES NO
  • If female and applicable: Age of first menstrual period …………Age at menopause……………...

Number of years of HRT (hormone replacement therapy) use…………….

  • Have you or any family member been seen by a Genetics department in the past YES NO

If yes, name of family member and genetics service visited………………………………………………………..

  • Some types of genetic cancer are slightly more common in Jewish families.

Is there any Jewish ancestry in your family (on mother’s or father’s side)?YES NO

  • Are you and your partner blood related, for example, cousins?YES NO
  • Have you suffered from any form of cancer yourself?

If yes, please give details including type of cancer, age at onset, specialist seen and hospital.

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

  • What are the main questions you would like to discuss with the Genetics Consultant/Counsellor?

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

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

For office use only.Genetic No:………………………..Date received in Department:…………………..

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Please complete the form below, giving as much information as possible about your immediate (blood) relatives, including those who have NOT had cancer.
If there is any information you do not know, perhaps someone in your family will be able to help you, otherwise leave that box empty. All the information you give will be held in confidence in the Clinical Genetics Unit. Please continue onto additional sheets of paper if necessary.
Relative / Full Name
(including maiden and any previous names) / Address
(inc postcode, or town/city if unknown)
(even if this person has died) / Date of Birth
(or approx year if unknown) / Alive
Y/N / Date of death
(or approx year if unknown) /

If your relatives have/had cancer

Type of Age at Hospital where treated
Cancer diagnosis (town/city if unknown)

Your mother

Your father
Your mother’s mother
Your mother’s father
Your father’s mother
Your father’s father
Your mother’s brothers & sisters (please state if male or female)

Please put any other relevant information on the back of this form

Relative / Full Name
(including maiden and any previous names) / Address
(inc postcode, or town/city if unknown)
(even if this person has died) / Date of Birth
(or approx year if unknown) / Alive
Y/N / Date of death
(or approx year if unknown) /

If your relatives have/had cancer

Type of Age at Hospital where treated
Cancer diagnosis (town/city if unknown)
Your father’s brothers & sisters(please state if male or female)
Your own brothers & sisters
(please state if full or half and if male or female)
Your own children
(please state if male or female)
Other relatives diagnosed with cancer including howrelated to you e.g. mother’s, father’s sister

Version 4 – dated 10.06.14Page 1of 3