PATIENT INFMATION : Address: (Last) (First) (Middle) (Last) (City) (State) (Zip) Home Phone: Cell Phone: Email address: Birth date: : Gender: When is the best time to contact you? May we email you for additional information? Please tell us the best way to contact you: Home Email Cell Who referred you for counseling? What is the reason you have been referred for counseling? Have you had If yes, what was the test? What were the results? What is the highest level of Elementary school Middle school High school education you completed? Some college College degree Graduate/Professional degree What is your occupation? Your current height: Your current weight: Page 1 of 10
Your background All Participants Ethnic Background? Hispanic/Latino Not Hispanic/Latino What is your race or White Black Hispanic Asian or Pacific Islander ethnic background? E. Indian Native American Indian/Eskimo/Aleut French Canadian Mediterranean/Greek/Italian Please check all that apply Multiracial Other: Ashkenazi Jewish descent Adopted What country is your mother s family originally from? What country is your father s family originally from? colonoscopy? skin exam? Your Health History All Participants Colon Cancer Screening Yes, when: What were the results? No If yes, how often do you typically repeat colonoscopies? Skin Cancer Screening If yes, when: What were the results? If yes, how often do you typically repeat skin exams? Have you ever been told you have unusual skin findings (ex: lumps, bumps, lesions, light or dark spots)? Have you had any exposures that could affect cancer risks? Yes, what: No Exposures If yes, what were they (ex; radiation, chemical plants, work exposures, smoking)? Page 2 of 10
Do you have a history of smoking? Do you drink alcohol? If yes, how long did you/have you smoked for? How many packs per day? On average, how much do you drink? Health History Do you exercise? On average, how often do you exercise? What do you do for exercise? Do you have any ongoing health Briefly describe any health problems here: problems? bone marrow transplant? Have you ever received a blood transfusion? If yes, did you have a donor or were the stem cells yours? If yes, when was your last blood transfusion? Did you receive: packed blood whole blood platelets white blood cells? Any hospitalizations or surgeries? Please list them. Menstrual History Have you had a pelvic exam? Your Health History- Participants only When did you begin your menstrual cycles? Have you gone through menopause? Yes, age: No If yes, when was your last pelvic exam? What were the results? Years old Page 3 of 10
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? breast exam by a physician? Do you perform selfbreast exams? mammogram? breast biopsy? Result of last breast biopsy How many times have you been pregnant? How many children have you had? How old were you when you had your first child? If yes, for how long? years 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? If yes, when was your last one? If yes, how often? If yes, when was your last mammogram? What were the results? Any additional imaging ordered? If yes, what was it? If yes, how many have you had? # If yes, at what age(s)? Invasive (lobular or ductal carcinoma) (i.e. cancer) In-situ (DCIS or LCIS) (i.e. cancer) Atypical hyperplasia (AH) Other: Unknown Page 4 of 10
Biopsy type: Biopsy type: Other Biopsy History-All patients Result: Result: Cancer in which Breast? Right Left : Breast Cancer History (if applicable)-all Patients Lumpectomy left right Mastectomy left right Surgeon: Radiation therapy Radiation Oncologist: Chemotherapy Oncologist: Other treatment: What type of cancer were you diagnosed? : Other Personal Cancer History (if applicable)-all Patients Surgery: Surgeon: Radiation therapy Radiation Oncologist: Chemotherapy Oncologist: Other treatment: Page 5 of 10
Family History *If you need more space to complete the family history, please continue on a blank sheet of paper.* ( only is ok) You You, Your Parents, & Your Grandparents of cancer you are not Testing? Your Mother Your Father Your Mother s Mother Your Mother s Father Your Father s Mother Your Father s Father ( ) Child 1 Your Children of cancer Child 2 Child 3 Child 4 Child 5 Child 6 Child 7 Child 8 Page 6 of 10
Sibling 1 Your Brothers & Sisters (please indicate half sibling vs full sibling) of cancer Sibling 2 Sibling 3 Sibling 4 Sibling 5 Sibling 6 Sibling 7 Sibling 8 Niece 1: Niece 2: Niece 3: Niece 4: Nephew 1: Nephew 2: Nephew 3: Nephew 4: Your Nieces & Nephews (children of your brothers & sisters) of cancer you are not Page 7 of 10
#1 Your Aunts and Uncles (Mother s side) of cancer #2 #3 #4 #5 #6 #7 #8 Cousin 1: Cousin 2: Cousin 3: Cousin 4: Cousin 5: Cousin 6: Cousin 7: Cousin 8: Cousins (children of your Mother s brothers & sisters) of cancer Page 8 of 10
#1 Your Aunts & Uncles (Father s side) of cancer #2 #3 #4 #5 #6 #7 #8 Cousin 1: Cousin 2: Cousin 3: Cousin 4: Cousin 5: Cousin 6: Cousin 7: Cousin 8: Cousins (children of your Father s brothers & sisters) of cancer Page 9 of 10
if known and How related (example: Mother s father s father s sister or Jane Doe s mother s mother s brother) this helps in building your family tree Other Relatives Cancer of cancer First name #1 #2 #3 #4 #5 #6 #7 #8 **If family member had testing, please bring a copy of your family member s test result to your appointment. If we do not have a copy at your appointment, your insurance may not pay for testing. ** Do you have any questions or concerns for the counselor? Please fax or email this questionnaire before your appointment Fax: 214-820-9606 Email: cancers@bswhealth.org Thank you! Page 10 of 10