Cancer Genetics Risk Assessment Program Questionnaire

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Gyles Ellis
6 years ago
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1 We greatly appreciate you taking the time to complete this questionnaire and look forward to meeting you. Gathering this information prior to your appointment will help make your visit with us as efficient and productive as possible. You are encouraged to contact other relatives to confirm or obtain information, especially for more distant relatives. We understand that some information may be inaccessible or difficult to obtain we simply request that you do the best you can. Please complete & return questionnaire as well as any prior genetic test results at least ONE WEEK prior to your appointment (& bring originals to your appointment): Fax: (415) Mail: Cancer Genetic Risk Assessment Program, c/o Lauren Bowling California Pacific Medical Center 2351 Clay Street, Suite 134 San Francisco, CA Note: To protect your privacy we ask that you do NOT this questionnaire to us because is not secure. If we have not received your completed questionnaire one week prior to your appointment, you will be contacted and you may be asked to reschedule your appointment.

2 Part I: Basic Information Last Name First Name Maiden Name Date of Birth Home Phone Number Cellular Phone Number Work Phone Number Preferred Contact Number Referring Physician (or Relative) Hospital or Clinic Clinic Phone Number Clinic Fax Number Part II: Personal History - For WOMEN Only Did your mother take DES during her pregnancy with you? (DES, or Diethylstilbestrol, was a medication that was regularly given to women during pregnancy to prevent miscarriages) How old were you at menarche (when you had your first period)? Age: Have you ever taken birth control pills? If yes, how many years (in total)? Years: Never How many times have you been pregnant? Number: Never How old were you when you gave birth to your first child? Age: Did you breastfeed? If yes, how many months in total? Months: Never Have you ever had a breast biopsy? If yes, how many? Number: Never If yes, did the biopsy show any atypical cells (atypical ductal hyperplasia, LCIS, etc)? Yes Do Not Know Have you had a mastectomy (surgical removal of one or both breasts)? No One Both Have you had a partial hysterectomy (surgical removal of the uterus, ovaries not removed)? Yes Age: No Have you had an oophorectomy (surgical removal of the ovaries)? If yes, at what age? Yes - Years: No Have you ever taken estrogen replacement therapy? If yes, for how long (in total)? Yes - Years: No Have you ever taken Tamoxifen (to treat or prevent breast cancer)? If yes, for how long? Yes - Years: No Have you gone through menopause? If yes, at what age did your periods stop? Yes Age: No Yes Have you been diagnosed/told you have fibrocystic breasts? Yes No Have you been diagnosed with uterine fibroids? Yes No Cancer Genetics Risk Assessment Program Questionnaire Page 2 of 10 No

3 Part III: Other Medical History For BOTH Men & Women Colon Screening: Have you ever had a colonoscopy? Yes No continue to Colon Polyps If yes: Age at first colonoscopy? How many colonoscopies have you had? Date of most recent colonoscopy? Colon Polyps: Do you have any history of colon polyps? If yes: Yes No Not Sure How many colon polyps have you had in total? >20 polyps Other: Please check box if you OR any relative has a history of: Thyroid structural lesions (e.g. adenoma, nodule, goiter) Yes - myself Yes - relative No/Not sure Lipomas (slow-growing fatty tumor under the skin) Yes - myself Yes - relative No/Not sure Autism spectrum disorder or mental retardation Yes - myself Yes - relative No/Not sure Part IV: Genetic Testing History If you or any of your relatives have had cancer genetic testing, please bring copies of any test results to your appt (if possible) Examples: BRCA ( BRACAnalysis ), BART Testing, MLH1, MSH2, MSH6, PMS2, EPCAM, APC, MYH, TP53 Have you ever had cancer genetic testing? Yes No Not Sure If Yes, what testing was done, what were your results, and what year testing was done? Have any of your relatives ever had cancer genetic testing? Yes No Not Sure If Yes, please describe what testing was done, what were the results, what year, name of relative, and how the relative is related to you. Example: Mary Smith (My mother s sister) BRCA Test- Positive for BRCA1 185delAG mutation in 2008 Part V: Family History General Questions Are any of your blood relatives of Ashkenazi (Eastern European) Jewish decent? Yes No Not Sure What is your mother s ancestry/ethnic background? (e.g. German, Polish, African, etc) What is your father s ancestry/ethnic background? (e.g. German, Polish, African, etc) Has anyone in your family married a blood relative? No Not Sure Yes, list which relatives and how they are related: Cancer Genetics Risk Assessment Program Questionnaire Page 3 of 10

4 Part V: Detailed Family History Information INSTRUCTIONS Please read carefully 1. Complete the tables as shown in the examples at the top of this first page. 2. List all family members, both those with and without cancer. 3. If your family is large, you may photocopy or add more sheets of paper at the end. 4. You may find it helpful to contact other relatives to confirm or get additional information about more distant relatives. We understand that sometimes information is not available to you or may be difficult to obtain. If you do not know much about your family history, do the best you can. Any information is helpful. 5. If exact age is unknown, give an approximate age or age range (e.g or 50s). 6. If person is living, leave age at death column blank. If person is deceased, leave age column blank. 7. If person has never had cancer, leave cancer column and age at diagnosis column blank. Your Immediate Family (Please indicate if your children are from different partners) RELATIONSHIP LAST NAME, FIRST (MAIDEN) AGE SEX CANCER AGE AT AGE AT CAUSE OF M/F DIAGNOSIS DEATH DEATH EXAMPLE Smith, Mary (Doe) 51 F Breast - Estrogen/Hormone+ 45 EXAMPLE Smith, Susan (Doe) F 80s Old age EXAMPLE Doe, John 65 M Prostate, Melanoma 62, 64 EXAMPLE Smith, Jane (Doe) F Cancer Type Unknown? 60s 60s Unknown You Your Partner Child Child Child Child Child Child Child Cancer Genetics Risk Assessment Program Questionnaire Page 4 of 10

5 Your Brothers & Sisters (If you have half-brothers or half-sisters, please indicate if you share the same mother or father) RELATIONSHIP LAST NAME, FIRST (MAIDEN) AGE SEX CANCER AGE AT AGE AT CAUSE OF BROTHER/SISTER M/F DIAGNOSIS DEATH DEATH Your Nieces & Nephews (Children of your brothers & sisters) RELATIONSHIP LAST NAME, FIRST AGE SEX CANCER AGE AT AGE AT CAUSE NAME OF YOUR NIECE/NEPHEW (MAIDEN) M/F DIAGNOSIS DEATH OF SIBLING WHO IS DEATH THE PARENT 0 1 Cancer Genetics Risk Assessment Program Questionnaire Page 5 of 10

6 Your MOTHER S Family RELATIONSHIP LAST NAME, FIRST (MAIDEN) AGE SEX CANCER AGE AT AGE AT CAUSE OF M/F DIAGNOSIS DEATH DEATH Your Mother Mother s Mother (Your Grandmother) Mother s Father (Your Grandfather) Your MOTHER S SIBLINGS (For half-aunts/uncles, please indicate if they share the same mother or father as your mother) MOTHER S SIBLINGS LAST NAME, FIRST (MAIDEN) AGE SEX CANCER AGE AT AGE AT CAUSE OF (Your Aunts & Uncles) M/F DIAGNOSIS DEATH DEATH Cancer Genetics Risk Assessment Program Questionnaire Page 6 of 10

7 Your Maternal First Cousins (Children of your mother s brothers & sisters) LAST NAME, FIRST AGE SEX CANCER AGE AT AGE AT CAUSE NAME OF YOUR COUSIN (MAIDEN) M/F DIAGNOSIS DEATH OF MOTHER S SIBLING DEATH WHO IS THE PARENT Cancer Genetics Risk Assessment Program Questionnaire Page 7 of 10

8 Your FATHER S Family RELATIONSHIP LAST NAME, FIRST (MAIDEN) AGE SEX CANCER AGE AT AGE AT CAUSE OF M/F DIAGNOSIS DEATH DEATH Your Father Father s Mother (Your Grandmother) Father s Father (Your Grandfather) Your FATHER S SIBLINGS (For half-aunts/uncles, please indicate if they share the same mother or father as your father) FATHER S SIBLINGS LAST NAME, FIRST (MAIDEN) AGE SEX CANCER AGE AT AGE AT CAUSE OF (Your Aunts & Uncles) M/F DIAGNOSIS DEATH DEATH Cancer Genetics Risk Assessment Program Questionnaire Page 8 of 10

9 Your Paternal First Cousins (Children of your father s brothers & sisters) LAST NAME, FIRST AGE SEX CANCER AGE AT AGE AT CAUSE NAME OF YOUR COUSIN (MAIDEN) M/F DIAGNOSIS DEATH OF FATHER S SIBLING DEATH WHO IS THE PARENT Cancer Genetics Risk Assessment Program Questionnaire Page 9 of 10

10 Other family members WITH CANCER that are NOT listed in prior sections RELATIONSHIP LAST NAME, FIRST (MAIDEN) AGE SEX CANCER AGE AT AGE AT CAUSE OF TO YOU M/F DIAGNOSIS DEATH DEATH EX. Maternal Harris, Elizabeth (Brown) F Female Uterine or 40s 51 Cancer? Grandmother s sister Ovarian? EX. Father s Cousin Miller, Betty (Jones) 60s F Breast 50s His Father s Brother s Daughter Cancer Genetics Risk Assessment Program Questionnaire Page 10 of 10

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?