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? May we email you if we need additional information? Please tell us how to contact you: Home Email Cell Who referred you for genetic counseling? What is the reason you have been referred for genetic counseling? Have you or any family member had genetic testing before? Office Use- ID: Other family members in HCRP Genetics Questionnaire Page 1 of 6
What is your race or ethnic background? Please check all that apply Adopted 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? 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? (ex; radiation, chemical plants, work exposures, smoking) Genetics Questionnaire Page 2 of 6
Do you have any ongoing health problems? Yes Briefly describe any health problems here: Revised 11-14-2012 Your Health History Female Participants only Menstrual History 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? times have you been pregnant? children have you had? How old were you when you had your first child? If yes, for how long? years 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 If yes, how many years? Type At what age did you start? If yes, reason: If yes, at what age? If yes: One ovary Both ovaries If yes, reason: If yes, at what age? Yes If yes, how many have you had? # If yes, at what age(s)? Invasive (lobular or ductal carcinoma) In-situ (DCIS or LCIS) Atypical hyperplasia (AH) Other: Unknown Genetics Questionnaire Page 3 of 6
Biopsy type: Biopsy type: Biopsy History Result: Result: Cancer in which Breast? Right Left Age at diagnosis: Breast Cancer History (if applicable) Lumpectomy left right Mastectomy 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): Genetics Questionnaire Page 4 of 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 Mom s sister s daughter Age w or Age at Death (N or D) (ex: 55 N) Location of cancer (ex: breast, thyroid, colon, etc) 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) Genetics Questionnaire Page 5 of 6
Your Family Tree Revised 11-14-2012 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 Dad/Mom) Ages brothers do you sons do you maternal uncles do you paternal uncles do you Total (Indicate half siblings Dad/Mom) Ages Do you have any questions or concerns for the genetic counselor? Genetics Questionnaire Page 6 of 6