Sydney Cancer Genetics Family History Questionnaire
Thank you for taking the time to complete your family history. A glance into your past can provide clues to whether or not your family has a higher risk of cancer than the general population. We use the information you provide to personalise screening and other cancer risk reducing strategies for you and your family. It remains confidential.
Record all relatives, whether they have had cancer or not. Include for each person:
Full Name and Date of Birth (or approximate age if date of birth not known)
If they had cancer, how old were they when diagnosed and what type of cancer it was
For relatives who have died, record the age they were when they died and cause of death
Some documents that can be helpful regarding any cancer in your family are:
doctor’s letters describing the type of cancer and any treatment
pathology reports about the type of cancer
death certificates
the genetic test report, if genetic testing has been performed or contact details of the genetic testing service.
Start with yourself. Also record your family’s ethnicity (eg British, Ashkenazi Jewish, Chinese). Then record your first degree relatives (children, brothers and sisters, parents), followed by your second degree relatives (grandparents, aunts and uncles, nieces and nephews). Include any third degree relatives (cousins, great-aunts and great-uncles) if they have had cancer.
Family history for:
Ethnicity (eg Ashkenazi Jewish)
Any genetic testing? If so, who, where it was done and result
Relation / Name / Date of Birth / Cancer? Age, type / If deceased, age and cause
self / Sue Smith / 1/01/1970 / Breast cancer at 45
mother / Jane Smith / 1/01/1945 / ovarian cancer at 40 / 42, ovarian cancer
father / Rob Smith / 1/01/1940 / No
brother / Peter Smith / 1/01/1973 / No
sister / Anne Smith / 1/01/1975 / No
mother’s brothers / etc...
Family history for:
Name, date of birth
Ethnicity (eg Ashkenazi Jewish)
Any genetic testing? If so, who, where it was done and result
Relation / Name / Date of Birth / Cancer? Age, type / If deceased, age and cause
Self
Sister(s)
Brother(s)
Mother
Father
Mother's father
(maternal grandfather)
Mother's mother
(maternal grandmother)
Father's father
(paternal grandfather)
Father's mother
(paternal grandmother)
Mother's sister(s)
(maternal aunts)
Mother's brother(s)
(maternal uncles)
Father's sisters(s)
(paternal aunts)
Father's brother(s)
(paternal uncles)
Your children
Your nieces and nephews : state parent
(your brothers’ and sisters’ children
Other relatives with cancer:
(include who related to eg:
Dad’s sister Jane’s son)
Clinics at Ultimo and Wahroonga. Telehealth to rural and regional Australia
All Correspondence: PO Box 845, Broadway, NSW, 2007
All appointments: (+61 2) 9304 0438 Fax: (+61 2) 9304 0468 E:
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www.SydneyCancerGenetics.com.au
Hereditary Health and Hope
Rooms at NHOG, Suite 403, SAN Clinic, 185 Fox Valley Rd, Wahroonga, NSW, Australia
T: +61 2 94738833 F: +61 2 94738830 E:
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www.SydneyCancerGenetics.com.au
Hereditary Health and Hope