Hereditary Cancer Risk Program Family History and Risk Assessment Questionnaire Please answer questions to the best of your ability in order to help us establish your risk assessment. Write in unk (unknown) for information not known. If you have any questions or if you need to schedule/change an appointment, please call 214-820-9600 Please send or fax this completed questionnaire (page 2-7) to us at least 1 week prior to your appointment (Fax: 214-820-9606) Page 1 of 7
Participant Information Name: (Last) (First) (Middle) Address: (Street) (City) (ST) (Zip) Home Phone: Work Phone: Cell Phone: Email address: Birth date: Age: Social Security : Spouse Name (optional): (this is for purpose of building your family tree) When is the best time to contact you? May we email you if we need additional information? Please tell us how to contact you: Work Home Email 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 (office use) Page 2 of 7
Do you have or did you have a history of breast problems? Have you ever had a breast biopsy? Your Breast History all participants, including Males If yes, describe: If yes, how many have you had? # Result of last biopsy Breast Cancer Which Breast? Right Left Both Age at diagnosis: Other Cancer: Type Age at diagnosis: Other Cancer: Type Age at diagnosis: Atypical hyperplasia In-situ (DCIS or LCIS) Invasive (lobular or ductal carcinoma) Other: Unknown If you have ever been diagnosed with cancer, please complete the following section Lumpectomy- Left Right age Mastectomy- Left Right age Surgeon: Radiation therapy Radiation Oncologist: Chemotherapy Other treatment: Oncologist: Surgery: Other treatment: Physician: Surgery: Other treatment: Physician: Page 3 of 7
Family History Please list all of your family Members that have been affected by Cancer Name First Name only o.k. M (male)or F (female) Relationship -Please Be Specific- Examples: Aunt-Moms Side, Uncle-Dads side, Great aunt -Dads Father s sister, Cousin - Aunt Jennie s daughter Moms side Age w or Age at Death (N or D) (ex: 55 N) Location of cancer (ex: breast, lung, colon, etc) For breast, indicate if bilateral; (cancer in both breasts) Age of cancer diagnosis (Estimate if you are not certain) Page 4 of 7
Family Tree 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 Personal Risk Assessment What is your race or ethnic background? (this can indicate certain risks) 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 What country is your mother s family from? What country is your father s family from? Adopted What is the highest level of education you completed? Elementary School Middle School High School Some College College Degree Graduate Degree Professional School What is your Occupation? Page 5 of 7
Your current height Your current weight Colon Cancer Screening Dermatological Menstrual History Your Health History (this information is used in calculating cancer risks) Have you ever had a colonoscopy?, when: What were the results? Have you ever been told you have unusual skin findings (ex: lumps, bumps, lesions, light or dark spots)?, what: Your Health History Female Participants only (this information is used in calculating cancer risks) When did you begin your menstrual cycles? Years old Pregnancy History (if applicable) Have you ever taken birth control pills? Have you ever taken Hormone therapy? Type Have you had your Uterus removed? Have you gone through Menopause? At what age? Was menopause induced by: Chemotherapy or other medications Surgery Natural times have you been pregnant? children have you had? How old were you when you had your first child? yrs For how long? years If yes, how many years? At what age did you start? If yes, reason: Have you had your ovaries removed? If yes: One ovary Both ovaries If yes, reason: Page 6 of 7
Tobacco Use Do you ever drink alcoholic beverages? Your Lifestyle History All Participants Do you smoke? For how many years? Used to smoke, but have quit years did you smoke? Do you use other types of tobacco? What kind? beverages per week? Do you exercise regularly? Do you have any ongoing health problems? Do you have any questions or concerns for the genetic counselor? Briefly describe any health problems here: Page 7 of 7