Cancer Genetics Baylor All Saints Medical Center at Fort Worth

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Melvin Spencer
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1 Cancer Genetics Baylor All Saints Medical Center at Fort Worth Thank you for your interest in the Hereditary Cancer Risk Program (HCRP). Please complete the family history and risk factor questionnaire included in this packet (page 2-7) and mail, or fax it to us before your appointment. Our fax number is Postal mail: Cancer Genetics, 3410 Worth St., suite 250, Dallas, TX Your appointment will be in the: Joan Katz Breast Center (on the Baylor Fort Worth Campus, map attached.) 1400 Eighth Avenue Fort Worth, TX Self parking and valet parking are both available. If for some reason you cannot attend your appointment, please call as soon as possible to reschedule. Thank you for your consideration. Important Information About Genetic Testing: If someone else in your family has already had genetic testing related to cancer it is very important that you obtain these records and bring them with you to your appointment. If you choose to have genetic testing, your blood sample will be drawn immediately after your genetic counseling appointment. Most health insurance carriers cover the cost of genetic testing depending on your personal and family history of cancer Some insurance carriers have certain criteria for testing, it is recommended that you be aware of your coverage level for outpatient (minor) diagnostic testing as well as your deductible level to determine your estimated out of pocket cost. If you have any questions, please call us at

2 Patient Information Name: (Last) (First) (Middle) Address: (Street) (City) (ST) (Zip) Home Phone: Cell Phone: address: Birth date: _ Age: Social Security.: When is the best time to contact you? May we you if we need additional information? Please tell us how to contact you: Work Home Cell Who referred you to the Hereditary Cancer Risk Program? What is the reason you have been referred to the Hereditary Cancer Risk Program? Office Use- ID: Other family members in HCRP 2

3 What is your race or ethnic background? If you are multiracial, check all that apply Your background All Participants White Black Hispanic Asian E. Indian French Canadian Mediterranean/Greek/Italian Native American Indian Multiracial Other: Ashkenazi Jewish descent Adopted What country is your mother s family from? What country is your father s family from? What is the highest level of education you completed? Elementary school Middle school High school Some college College degree Graduate/Professional degree What is your Occupation? Your current height: Your current weight: Colon Cancer Screening Dermatological Your Health History All Participants Have you ever had a colonoscopy? Yes, when: What were the results? Have you ever been told you have unusual skin findings (ex: lumps, bumps, lesions, light or dark spots)? Yes, what: Have you had any exposures that could affect cancer risks? Yes (ex; radiation, chemical plants, work exposures, smoking) 3

4 Do you have any ongoing health problems? Yes Briefly describe any health problems here: Menstrual History Your Health History Female Participants only When did you begin your menstrual cycles? Years old Have you gone through menopause? Yes, age: Pregnancy History (if applicable) Have you ever taken birth control pills? Have you ever taken hormone replacement therapy? Have you had your Uterus removed? Have you had your ovaries removed? Have you ever had a breast biopsy? Result of last breast biopsy times have you been pregnant? children have you had? How old were you when you had your first child? Yes If yes, for how long? years Yes If yes, how many years? Type At what age did you start? Yes If yes, reason: Yes If yes: One ovary Both ovaries If yes, reason: Yes If yes, how many have you had? # Invasive (lobular or ductal carcinoma) In-situ (DCIS or LCIS) Atypical hyperplasia (AH) Other: Unknown 4

5 Biopsy type: Biopsy type: Biopsy History Result: Result: Cancer in which Breast? Right Left Both Age at diagnosis: Breast Cancer History (if applicable) Lumpectomy Mastectomy- left right left right Surgeon: Radiation therapy Radiation Oncologist: Chemotherapy Other treatment: Oncologist: What type of cancer were you diagnosed with? Age at diagnosis: What type of cancer were you diagnosed with? Age at diagnosis: Personal Cancer History (if applicable) What treatment did you Physician(s): What treatment did you Physician(s): 5

6 Family History Please list all of your family Members that have been affected by Cancer Name (First name only okay) M (male) or F (female) Relationship -Please Be Specific- Examples: Aunt Mom s side, Great aunt Dad s father s sister, Cousin - Aunt Jennie s daughter Age w or Age at Death (N or D) (ex: 55 N) Location of cancer (ex: breast, thyroid, colon, etc) For breast, indicate if cancer is in both breasts (bilateral) Age of cancer diagnosis (Estimate) Has anyone in your family tested positive for a mutation in a cancer gene? Yes if yes, what gene? (if yes, please bring a copy of your family member s test result to your appointment) 6

7 Your Family Tree Mother Age: Father Age: (now or age deceased) (now or age deceased) sisters do you daughters do you maternal aunts do you paternal aunts do you Total (Indicate half siblings) Ages brothers do you sons do you maternal uncles do you paternal uncles do you Total (Indicate half siblings) Ages Do you have any questions or concerns for the genetic counselor? 7

Patient Information. Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) Home Phone: Cell Phone: address:

Patient Information. Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) Home Phone: Cell Phone: address: Patient Information Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) Home Phone: Cell Phone: Email address: Birth date: _ Age: Social Security.: When is the best time to contact you?