Thank you for your interest in the Cancer Genetics Program at Mount Sinai Roosevelt and Mount Sinai Saint Luke’s Hospitals. Please use this form to help you prepare for your appointment. We recognize that obtaining all of this information may be difficult, and understand that not everyone will be able to do so. Please come to your appointment regardless of the amount you are able to collect. Our genetic counselor can work with you and any information you are able to provide.
Health History
PERSONAL HEALTH HISTORY
- How old were you when you had your first menstrual period?
- Do you still have your menstrual period?
If no, at what age did you stop having your period? / Age:______
- Have you ever used birth control pills?
If yes, please estimate the total number of years taken. / Years:______
- Have you ever used estrogen or hormone replacement therapy?
If yes, for how many years? / Age Range:______
- Have you ever had your uterus or ovaries removed?
If yes, what was the indication for surgery? / ______
______
- Have you ever had a breast biopsy?
If yes, how many in total? / ______
- When was your last clinical breast exam?
- Have you ever had a mammogram?
If yes, list the date of your last mammogram. / Date:______
- Have you ever had a breast sonogram/ultrasound
If yes, list the date of your last sonogram. / Date:______
- Have you ever had a breast MRI?
If yes, list the date of your last MRI. / Date:______
- When was your last pelvic exam with a gynecologist?
- Have you ever had a transvaginal ultrasound?
If yes, list the date of your last ultrasound. / Date:______
- Have you ever had blood drawn for a CA-125?
If yes, list the date of your last test. / Date:______
- Have you ever had a colonoscopy?
If yes, list the date of your last colonoscopy. / Date:______
Have any colon polyps been removed? / Yes / No
How many? / Number of polyps:______
Cancer History
Example
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis
Mother / Doe (Smith), Jane / F / Y / 52 / Breast, 46
Uterine, 52
Grandfather / Smith, John / M / Y / 80 / Breast, 75
Grandmother / Smith, Mary / F / N / 78 / No Cancer
PERSONAL CANCER HISTORY
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age / Cancers and Age at Diagnosis
IMMEDIATE FAMILY CANCER HISTORY
Your Children
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis
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2
3
4
5
Your Brothers and Sisters
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis / Shared Parent(s)
Mom
Y/N / Dad
Y/N
Your Nieces and Nephews
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis / Name of Parent Related to You
MATERNAL FAMILY CANCER HISTORY
Mother’s Family
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis
Your Mother
Grandmother
Grandfather
Aunts and Uncles
Your First Cousins on Your Mother’s Side
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis / Name of Parent Related to You
PATERNAL FAMILY CANCER HISTORY
Father’s Family
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis
Your Father
Grandmother
Grandfather
Aunts and Uncles
Your First Cousins on Your Father’s Side
Last Name (Maiden), First / Sex
M/F / Alive
Y/N / Current Age, or Age at Death / Cancers and Age at Diagnosis / Name of Parent Related to You
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