Hereditary Cancer Risk Assessment Questionnaire

Hereditary Cancer Risk Assessment Questionnaire

Patient Name: ______DOB: ______

1. Have you or has anyone in your family been diagnosed with breast cancer at

age 45 or younger?YESNO

If yes, please complete the following:

MyselfAge at Diagnosis_____

Sister(s)Age at Diagnosis_____

MotherAge at Diagnosis_____

DaughterAge at Diagnosis_____

GrandmotherAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

AuntAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

NieceAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

1. Have two relatives on the same side of the family been diagnosed with breast

cancer,one under 50?YESNO

If yes, please complete the following:

MyselfAge at Diagnosis_____

Sister(s)Age at Diagnosis_____

MotherAge at Diagnosis_____

DaughterAge at Diagnosis_____

GrandmotherAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

AuntAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

NieceAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

1. Have three relatives on the same side of the family been diagnosed with breast

cancer,at any age?YESNO

If yes, please complete the following:

MyselfAge at Diagnosis_____

Sister(s)Age at Diagnosis_____

MotherAge at Diagnosis_____

DaughterAge at Diagnosis_____

GrandmotherAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

AuntAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

NieceAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

1. Have you or has anyone in your family been diagnosed with breast cancer in both

breasts OR twice in one breast, with one of the diagnosis being at age 50 or younger?YESNO

If yes, please complete the following:

MyselfAge at Diagnosis_____

Sister(s)Age at Diagnosis_____

MotherAge at Diagnosis_____

DaughterAge at Diagnosis_____

GrandmotherAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

AuntAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

NieceAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

1. Has anyone in your family been diagnosed with male breast cancer?YESNO

If yes, please complete the following:

BrotherAge at Diagnosis_____

FatherAge at Diagnosis_____

SonAge at Diagnosis_____

GrandfatherAge at Diagnosis_____Mother’s Side___ Father’s Side___

UncleAge at Diagnosis_____Mother’s Side___ Father’s Side___

NephewAge at Diagnosis_____Mother’s Side___ Father’s Side___

CousinAge at Diagnosis_____Mother’s Side___ Father’s Side___

*If yes, additional family history is required.

1. Have you or has anyone in your family been diagnosed with ovarian cancer?YESNO

If yes, please complete the following:

MyselfAge at Diagnosis_____

Sister(s)Age at Diagnosis_____

MotherAge at Diagnosis_____

DaughterAge at Diagnosis_____

GrandmotherAge at Diagnosis_____Mother’s Side___ Father’s Side___

AuntAge at Diagnosis_____Mother’s Side___ Father’s Side___

NieceAge at Diagnosis_____Mother’s Side___ Father’s Side___

CousinAge at Diagnosis_____Mother’s Side___ Father’s Side___

1. Are you of Ashkenazi (Eastern European) Jewish descent with breast or ovarian

cancer in your maternal or paternal family history?YESNO

We ask this question because this group is at high hereditary risk.

1. Have you or has anyone in your family been diagnosed with both pancreatic and breast

cancer or both pancreatic and ovarian cancer at any age?YESNO

If yes, please complete the following:

MyselfAge at Diagnosis_____

Sister(s)Age at Diagnosis_____

MotherAge at Diagnosis_____

DaughterAge at Diagnosis_____

GrandmotherAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

AuntAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

NieceAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

1. Have you or has anyone in your family been diagnosed with triple negative breast

cancer under age 60?YESNO

If yes, please complete the following:

MyselfAge at Diagnosis_____

Sister(s)Age at Diagnosis_____

MotherAge at Diagnosis_____

DaughterAge at Diagnosis_____

GrandmotherAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

AuntAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

NieceAge at Diagnosis_____Mother’s Side ___ Father’s Side ___

1. Have two relatives, one under 50 or three relatives at any age, been diagnosed with colon

cancer, uterine cancer, ovarian cancer, small bowel cancer, stomach cancer, pancreatic

cancer, kidney/ureter cancer, biliary tract cancer or brain cancer?YESNO

If yes, please complete the following: TYPE:

MyselfAge at Diagnosis______

Sister(s)Age at Diagnosis______

Brother(s)Age at Diagnosis______

MotherAge at Diagnosis______

FatherAge at Diagnosis______

DaughterAge at Diagnosis______

SonAge at Diagnosis______

GrandmotherAge at Diagnosis_____Mother’s Side ___ Father’s Side ______

GrandfatherAge at Diagnosis_____Mother’s Side ___ Father’s Side ______

AuntAge at Diagnosis_____Mother’s Side ___ Father’s Side ______

UncleAge at Diagnosis_____Mother’s Side ___ Father’s Side ______

NieceAge at Diagnosis_____Mother’s Side ___ Father’s Side ______

NephewAge at Diagnosis_____Mother’s Side ___ Father’s Side ______

*If just one family member then testing may not be indicated but changes to management should be made.

1. Do you or does anyone in your family have a known BRCA or Lynch mutation?YESNO

If yes, please complete the following:

Relationship to you: ______Results:______

I______completed this form on ______.

PATIENT SIGNATUREDATE

I ______reviewed this form on ______.

PROVIDER SIGNATUREDATE

Thank you for completing this survey, it will help us to determine your risk for hereditary cancer syndromes.