Welcome to the Winship Cancer Institute Genetic You have been scheduled for a 90 minute new patient genetic counseling session. Please call 404-778-1900 if you will be late for your appointment, need to reschedule or need assistance with directions. At Winship, we believe it is important to partner with our patients, and we want you to have the best experience possible. For this to occur, we need to have information from you and your doctor prior to your appointment. From you: A Health and Family History Questionnaire is attached for you to complete and return to us prior to your appointment. From your doctor (if applicable): Pathology reports Clinic note from most recent physician visit Colonoscopy/endoscopy reports Copy of genetic test report (self or family member) Please fax this information to us at 404-778-3888 prior to your appointment. Include your name, appointment date and time and location on all faxes so that we can be sure that the information gets to your genetic counselor. If you do not have access to a fax machine, please bring the completed information with you or mail to: Winship Cancer Institute at Tufts House Genetic 2004 Ridgewood Drive Atlanta, GA 30322 Genetic counseling is a medical service provided for a fee. The Emory Clinic will bill your insurance company for your genetic counseling session. Please bring your insurance card to your appointment. You are responsible for any charges not covered by your insurance and any pre- authorization for the counseling visit that your insurance company may require. The genetic counselor will work with the testing laboratory and your insurance company to complete any insurance authorization that may be necessary for genetic testing. Please understand that we are not able to authorize genetic testing prior to your visit. Thank you for choosing the Winship Cancer Institute Genetic. We look forward to meeting you! Christine Stanislaw, MS, CGC Director of Genetic
Clinics and Locations Counselor Christine Stanislaw, MS, CGC Fabienne Ehivet, MS, CGC Christine Tallo, MMSc Practice Locations Winship at Tufts House Winship at Saint Joseph s Hospital and Tufts House Winship at Midtown Hospital and Tufts House Clinic Locations Directions and maps to all clinic locations can be found at www.winshipcancer.emory.edu under Patient Care then Clinics and Centers. Winship at Tufts House Limited parking is available in the Tufts House parking lot and you are welcome to park there for your genetic counseling appointment. We will provide you with a parking pass for the Tufts House parking lot. Additional parking is available at the Winship valet stand and the Emory Clinic patient parking lot. Please come in the main entrance and use the phone to call the genetic counselor you are scheduled to see. Genetic Counselor numbers will be provided by the phone. Winship at Midtown Hospital Where to go under construction Service to begin Fall 2015 Winship at Saint Joseph s Hospital Where to go under construction Service to begin November 2015
Patient name: Date of birth: Date of appointment: Appt. Time: Appointment Location: Tufts House St Joseph s Midtown Which genetic counselor you are seeing? Christine Stanislaw Fabienne Ehivet Christine Tallo Why were you referred for genetic counseling? Have you or a family member previously had genetic testing for cancer susceptibility? YES* NO If yes, what testing was performed and what was the result? *Please bring a copy of previous gene c tes ng results on yourself or family member to your appointment. Have you ever been diagnosed with cancer? YES NO If yes, please list the type or site of cancer and your age at diagnosis. Please describe your cancer treatment (surgery, chemotherapy, radiation, etc.): Please list any medical conditions you have or have had. Examples include diabetes, high blood pressure, heart disease, osteoporosis, thyroid disease, etc. Please list any surgeries you have had and the year you had them.
Questionnaire Page 2 Age/year of your last complete physical: Have you ever had a colonoscopy? YES NO Colonoscopy history: Total colonoscopies: Age at first colonoscopy: Age at most recent colonoscopy: Frequency of colonoscopies: Total number of polyps found to date: Please complete the table below to the best of your knowledge Age/Year (approximate) Total polyps found Polyp type (hyperplastic, adenoma, tubular adenoma, sessile serrated adenoma, hamartoma, juvenile) Have you ever had an upper endoscopy (EGD)? YES NO If yes, age/year or your last upper endoscopy? What was the reason for endoscopy? Have you ever had a PSA blood test to screen for prostate cancer? YES NO If yes, age/year of your FIRST PSA blood test: How often do you have PSA blood tests? When was your last PSA blood test?
Questionnaire Page 3 Have you had any skin cancers or abnormal moles removed? YES NO Type of skin cancer? Age of diagnosis? Do you see a dermatologist regularly? YES NO If yes, how often? Have you ever been diagnosed with thyroid nodules or goiter? YES NO Do you smoke? YES NO Former Smoker How many years have you smoked? How many cigarettes do/did you smoke per day? When did you quit smoking? Do you drink alcoholic beverages? YES NO If yes, approximately how many drinks do you have per week? What is your ethnic background on your MOTHER s side (African American, Asian, European, Native American, etc)? What is your ethnic background on your FATHER s side (African American, Asian, European, Native American, etc)? Do you have any Ashkenazi Jewish (Eastern European Jewish) ancestry? YES NO
Questionnaire Page 4 YOUR CHILDREN Your Family History Any history of cancer? (if yes, please list type of cancer and age at diagnosis) YOUR SIBLINGS (BROTHERS AND SISTERS) Indicate S for full siblings (who have the same mother and father as you), M for siblings who share only your same mother, and F for siblings who share only your same father. S/M/F (see above) Any history of cancer? (if yes, please list type of cancer and age at diagnosis) Also please indicate if their have had cancer
Questionnaire Page 5 YOUR MOTHER Your Mother s Side Any history of cancer? (if yes, please list type of cancer and age at diagnosis) YOUR MOTHER S PARENTS (your maternal grandparents) Living Any history of cancer? (if yes, please list type of cancer and? (Y/ age at diagnosis) N) Maternal Grandmother Maternal Grandfather YOUR MOTHER S BROTHERS AND SISTERS (your maternal aunts and uncles) Indicate S for full siblings (who have the same mother and father as your mother), M for siblings who share only your mother s mother, and F for siblings who share only your mother s father. S/M/F (see above) Any history of cancer? (if yes, please list type of cancer and age at diagnosis) Also please indicate if their have had cancer
YOUR FATHER Your Father s Side Any history of cancer? (if yes, please list type of cancer and age at diagnosis) YOUR FATHER S PARENTS (your paternal grandparents) Paternal Grandmother Living? (Y/ N) Any history of cancer? (if yes, please list type of cancer and age at diagnosis) Paternal Grandfather YOUR FATHER S BROTHERS AND SISTERS (your paternal aunts and uncles) Indicate S for full siblings (who have the same mother and father as your father), M for siblings who share only your father s mother, and F for siblings who share only your father s father. S/M/F (see above) Any history of cancer? (if yes, please list type of cancer and age at diagnosis) Also please indicate if their have had cancer
Questionnaire Page 7 OTHER FAMILY MEMBERS (use this page for family members that didn t fit on the other pages, example your great grand parents, great aunts, etc.) Indicate P for fathers side of family and M for mothers side of family and their relationship to you Relationship to you P/M (see above) age at death Any history of cancer? (if yes, please list type of cancer and age at diagnosis) Also please indicate if their have had cancer