Cancer Risk Assessment Questionnaire

Transcription

1 Information about your health, lifestyle, and family history will help us determine your risk for cancer. If you already have cancer, it can help us determine the chance your cancer was caused by an inherited genetic change. Please complete this questionnaire as thoroughly as you can. The more detailed, accurate information you can provide us with, helps us give you the most comprehensive, accurate risk assessment. If you are uncertain about your family history, we strongly encourage you to speak with relatives who may have more information. Medical records (including pathology reports and/or genetic testing results) for yourself or anyone in your family with cancer / pre-cancer are extremely helpful to share with us. Please do your best to obtain this information and include these records with your completed questionnaire. For family members who are deceased, additional information may be located on their death certificate or medical records. This questionnaire can be returned to us by either of the following methods: Fax (preferred): (312) Mail: Insight Medical Genetics 680 N. Lake Shore Drive, Suite 1230 Chicago, IL We will contact you to begin scheduling your appointment within 2 business days of when we receive your paperwork. Appointments are typically scheduled within 2 weeks of when your paperwork is received. This allows adequate time for us to review your information. In some cases, the results of your counseling session and genetic testing may be helpful to your family members. If you would like, we can share your information with members of your family. Please sign and initial below if you would like for us to share this information with your close relatives., please share information from our counseling session and/or genetic testing with my first, second, and third degree relatives. This includes, but is not limited to, my parents, siblings, aunts and uncles, cousins, and grandparents. YOUR NAME SIGNATURE TODAY S DATE Page 1

2 PATIENT INFORMATION YOUR NAME DATE OF BIRTH MALE FEMALE HOME ADDRESS CITY / STATE / ZIP PREFERRED PHONE: SECONDARY PHONE: HOME WORK CELL HOME WORK CELL May we leave a voic with private medical information on your preferred phone? Is there anyone other than your doctor that you would like us to be able to speak with about your visit or testing results (for example: spouse, child)? If so, please indicate their name and relationship to you. INSURANCE INFORMATION PRIMARY INSURANCE COMPANY MEMBER ID NUMBER SUBSCRIBER S NAME GROUP ID NUMBER SUBSCRIBER S DATE OF BIRTH SECONDARY INSURANCE COMPANY MEMBER ID NUMBER SUBSCRIBER S NAME GROUP ID NUMBER SUBSCRIBER S DATE OF BIRTH REFERRING DOCTOR Please give us the full name, address, and phone number of the doctor who referred you to our service: Page 2

3 What questions would you like to have answered during your visit? AL MEDICAL HISTORY HAVE YOU EVER HAD If yes, please complete this table and provide us with your pathology report(s). If you have been diagnosed with more than one primary cancer, please use a new line for each cancer. How old were you when you were diagnosed with this cancer? Type of cancer? (where the cancer started, not where it may have spread) If breast cancer, please indicate which side cancer started (right/left) Did this cancer spread (metastasize) beyond the primary site? If this cancer spread, please indicate where in the body it spread (liver, lung, etc.) If you have had cancer, which of the following treatments have you received? Page 3

4 TREATMENT FOR HAVE YOU EVER HAD If yes, approximate dates of your treatment? If yes, with which hospital did you have this treatment? SURGERY? RADIATION? CHEMOTHERAPY? HORMONAL THERAPY: TAMOXIFEN? AROMATASE INHIBITOR? OTHER THERAPY? PLEASE SPECIFY ANY OTHER TREATMENT: TREATMENT FOR HAVE YOU EVER HAD A BREAST BIOPSY? If yes, when? IF, BIOPSY RESULTS? TREATMENT FOR Your mother s ethnic background (include Jewish ancestry): Your father s ethnic background (include Jewish ancestry): Page 4

5 FAMILY GENETIC TESTING HISTORY HAS ANYONE IN YOUR FAMILY HAD GENETIC TESTING FOR RISK? If you answered yes above, please provide us with a copy of these results. These are necessary before we can order genetic testing for you. HOW MUCH? HOW OFTEN? FOR HOW LONG? IF QUIT, WHEN? ALCOHOL? TOBACCO? CAFFEINE? YOUR REPRODUCTIVE HISTORY (FEMALES ONLY) NUMBER OF TOTAL PREGNANCIES: NUMBER OF CHILDREN (IF APPLICABLE): AGE AT FIRST PREGNANCY (IF APPLICABLE): DID YOU BREASTFEED? IF, FOR MANY MONTHS? AGE AT FIRST PERIOD: AGE AT MEPAUSE (IF APPLICABLE): AGE AT MOST RECENT PERIOD: HAVE YOU HAD A HYSTERECTOMY? DO YOU HAVE BOTH OVARIES? IF, PLEASE EXPLAIN: Page 5

6 HAVE YOU USED ORAL CONTRACEPTIVES OR A HORMONAL INTRAUTERINE DEVICE (IUD)? IF, FOR HOW MANY YEARS? HAVE YOU USED HORMONE REPLACEMENT THERAPY (HRT)? IF, FOR HOW MANY YEARS? PREVENTATIVE HEALTH MAINTENANCE Please indicate when you last had the following, or write never FEMALES ONLY MALES ONLY LAST MAMMOGRAM: LAST PROSTATE EXAM: LAST PELVIC EXAM / PAP: LAST PSA SCREENING: LAST COLOSCOPY: LAST COLOSCOPY: NUMBER OF POLYPS? NUMBER OF POLYPS? Page 6

7 FAMILY MEDICAL HISTORY The following tables request information about your relatives health. Please include all blood relatives on these forms, regardless of whether they have been diagnosed with cancer. If you don t have exact information, please fill in this form to the best of your knowledge. Approximate ages are okay! When listing the type of cancer, please indicate where the cancer started (e.g. breast cancer that spread to the lung should be identified as breast cancer). If the cancer is gynecologic ( woman s cancer ), please state if it started in the ovary, uterus, or cervix. If you are unsure, put gynecologic cancer. We appreciate as much information as possible. Here is an example of how to complete these family history forms: DIAGSIS TYPE(S) OF, OR PRE- FOUND Auntie Em 65 Living Yes 50 Breast YOUR PARENTS AND GRANDPARENTS: DIAGSIS TYPE(S) OF, OR PRE- FOUND MOTHER FATHER MOTHER S MOTHER MOTHER S FATHER FATHER S MOTHER FATHER S FATHER Page 7

8 YOUR CHILDREN: DIAGSIS TYPE(S) OF, OR PRE- FOUND YOUR SIBLINGS (BROTHERS AND SISTERS) AND NIECES/NEPHEWS DIAGSIS TYPE(S) OF, OR PRE- FOUND Page 8

9 YOUR MOTHER S BLOOD-RELATIVES (YOUR AUNTS, UNCLES, COUSINS) DIAGSIS TYPE(S) OF, OR PRE- FOUND YOUR FATHER S BLOOD-RELATIVES (YOUR AUNTS, UNCLES, COUSINS) DIAGSIS TYPE(S) OF, OR PRE- FOUND Page 9