This questionnaire is designed for the most common types of hereditary cancer and not appropriate for the assessment of rare syndromes. This is a graphical version of the Sample Cancer Family History Questionnaire. These questions are based on the clinical guidelines doctors use to determine whether you should be tested for one of the above syndromes. Warning! Biological Family History: Please fill out the following information where it applies to your biological family only. endstream endobj startxref Patient Name Date of Birth Age Gender (M/F) Today’s Date (MM/DD/YYYY) Health Care Provider . Myriad's Family Cancer History Tool. Provides tips, resources, and tools for family history collection in clinical practice. For people with disabilities, this document is available on request in other formats. If your family is very large, you may photocopy or add more sheets of paper. Other tools may be more appropriate for women with known mutations in either the BRCA1 or BRCA2 gene, or other hereditary syndromes associated with higher risks of breast cancer. List ALL family members, including those with and without cancer. 63 0 obj <>/Filter/FlateDecode/ID[<93EEFD8B81834A489B5A1CD48F17F540>]/Index[7 94]/Info 6 0 R/Length 179/Prev 117643/Root 8 0 R/Size 101/Type/XRef/W[1 3 1]>>stream Cancer Family History Questionnaire . Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. FAMILY HISTORY ENQUIRY FORM Please note the following when completing your questionnaire: Please give us details of those family members who have not had cancer. Outlines common inheritance patterns of conditions with an underlying genetic component. Please fill out this form with information about: ALL your relatives (those who have had cancer and those who have not) BOTH sides of your family (your mother’s and father’s side) For relatives who have had cancer: Please tell us what type of cancer (the part of the body where the cancer first started), and the age when the relative was first diagnosed with cancer. Leverage genetics and family history to identify and manage patients at high risk for cancer. Why have I been given a family history questionnaire? Childhood Medulloblastoma - Family Cancer History questionnaire %%EOF Cancer Family History Questionnaire. 2. Completing this questionnaire will help us to determine the risk of a hereditary cancer predisposition in your family. This questionnaire has been developed as a general family history collection tool. Studies have dem - ... By reviewing your personal and family history, your healthcare provider can determine whether or not you are a candidate for genetic testing. Cancer Family History Check Y or N Please list yourSELF or your FAMILY MEMBER listed above with CANCER Age of Diagnosis SELF MOTHER’S SIDE FATHER’S SIDE Colon Cancer diagnosed before age 50 Y N Endometrial/Uterine Cancer diagnosed before age 50 (Including yourself if diagnosed at any age) Y N Helps identify red flag… 7 0 obj <> endobj Cancer Risk Assessment Tool. Family History Questionnaire P: 6-66 providerscolor.com C1.0PAO uestionnaire 1/1 Colon/rectal Yes No Ovarian (peritoneal/ fallopian tube) Yes No Uterine (endometrial) Yes No ... Two or more cancers on the same side of the family A personal or family history of cancer at age 60 or younger You may find it helpful to contact other family members to get information about more distant relatives. If yes, then indicate family Family History Questionnaire. If you are uncertain about any information, please write in your best guess or write unknown. Instructions: This is a screening tool to determine if Myriad myRisk® Hereditary Cancer testing is right for you. h�b``0c``z�������01G��300�h�|��(0�j1t�'�N���L�c΃��K�۔Lx8N�~��a�\f���gj"8�;�l�Ɣ��9�3A��7�1��� BT���d� �T��gf`�� m�&� Title: Microsoft Word - Myriad Cancer Family History Questionnaire_PMRC Approved_1101612.docx Author: jbennett Created Date: 11/16/2012 10:57:46 AM This is important in assessing your cancer risk. Oregon Health & Science University – Knight Cancer Institute . Myriad Genetics’ Hereditary Cancer Quiz helps you to assess whether you might be a good candidate for genetic testing. h�bbd```b``�� `v*�d���`v0�\&EA� ����\�`s@$�v�� !«���wA$�E����>�F��L�A��^�y@���l�m��3��x0[L6#�#��šd�J;,�tŀɧ�O�$���?�0T��Mf`V���� �d&N See Other Risk Assessment Tools for more information. h��Xmo�8�+������ Xp���]����f�>���kK>I�m���)�/�ǻ��D����ea�h�1�p���D0O�#�Ib. Take the Quiz. Adult Brain Tumors - Family Cancer History questionnaire Questions used to gather family cancer history from participants in the Case-referent Study of Adults with Brain Tumors. Patient Name: Date of Birth: Age: Gender (M/F):Today’sDate(MM/DD/YY): Health Care Provider: Instructions: This is a screening tool for cancers that run in families. Cancer Family History Questionnaire PERSONAL INFORMATION Patient Name Date of Birth Age Gender (M/F) Today’s Date (MM/DD/YYYY) Health Care Provider Your Personal & Family History of Cancer is Important to Provide You With the Best Care Possible Please mark “Yes” or “No” below if there is a personal or family history of any of the following cancers. Because these diseases are … Cancer Family History Questionnaire. Cancer Genetics Family History Questionnaire . Please answer these questions as completely as possible. %PDF-1.5 %���� This is not a test, but rather a questionnaire to help determine risk so you can be prepared to talk to your doctor about further evaluation of your personal and family history of cancer. If you are unable to read or print, or wish to obtain the full document including the Guidelines Justification, Appendices, and References, please contact the New York State Genetic Services Program at 518-474-1222. 5. This may be because there are several cancers in your family or because you or a relative has had cancer at a young age. Cancer family history questionnaire Ask each patient to fill one out to capture 3 degrees of cancer history for both maternal and paternal family members. Cancer History Questionnaire To assess your personal hereditary cancer risk, please complete the questionnaire below and return it to your healthcare provider. CANCER FAMILY HISTORY QUESTIONNAIRE. Inheritance Patterns Factsheet. Instructions: 1) Please list all your blood relatives, (including living and deceased; both full- and half-siblings), and whether or not they have had cancer. Pedigree Tool.A template to record a pedigree with standard pedigree nomenclature. Patients were asked to report whether they or other members of their family had been diagnosed with breast cancer, sarcoma, bone cancer, lung cancer, brain cancer, adrenal cancer, prostate cancer, or another cancer, and at what age. It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. 0 Family History Collection Tips & Tools. 3. You can use this tool to collect a targeted family history by focusing on cancer diagnoses in the family and including the specific types of cancer and ages of diagnosis. This is a screening questionnaire for the common features of hereditary cancers. Please include cancers from both your biological maternal (mother’s) and paternal (father’s) sides of your family, when completing the answers. endstream endobj 8 0 obj <>>> endobj 9 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/Properties<>/MC1<>>>/Shading<>>>/Rotate 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 10 0 obj <>stream In most families, cancer occurs by chance and the risk to other people in the family is no different to that of the general population. Type(s) of Cancer Age(s) at Diagnosis Current Age You Immediate Family Total Number Number with Cancer Type(s) of Cancer Age(s) at Diagnosis Current If you take the quiz and find red flags in your own or your family’s health history, you may benefit from hereditary … After you complete the form to the best of your ability, bring it with you to your next doctor’s appointment and ask to discuss it. 4. To submit a request, please call 1-800-525-0127 (TDD/TTY call 711). Save time, reduce the cost of care, and improve outcomes by catching cancer early … A person is more susceptible to diseases like diabetes, hypertension, heart problems, cancer, and mental disorders when his or her family is positive for these disorders. Next to each statement, please list the relationship(s) to you and age of diagnosis for each … Family History Questionnaire for Common Hereditary Cancer Syndromes Patient Name: Physician: Date of Birth: Date Completed: Please mark below if there is a personal or family history of any of the following cancers. PERSONAL INFORMATION . Personal Information. The scgsquestionnaire collected data about cancer history for both the patient and the patient’s family. ¦¦O*#nYê'¿p“:ÏÈ{fáà8©®k¶#ÛCG×®Ÿ[ª¸‡�å¡`bPe¬\ј)ø¨eG=¬¤“¼1Ã3ßÏnú�áRïï�°�­v~¥WÆ8ê©ãîää¦_E.à’îÚR£h•{êsoë„:¥+Ñ—Ltå?³v™şLY–\ hT±•bı±ˆKHÙpşıÚj«¾bEJ8XlõzÎóâ¤úĞ,ùL“õ�mÊİÃÁ|©:^µ»ÈzŒÍ÷ğ¤OÚ�/°i÷u‰únùúúöÂ�© é�£Iá•ÂÇ‚e=®ãõ&4Có£ohw3j4Öx‡ìzÔeQ==v. The field deals with the role of genes and heredity in the health and well-being of a person. The medical significance of tracking the family genogramcame to light with the developments in medical genetics. 100 0 obj <>stream You should also send the form to your close relatives so they have the information to … Family History Questionnaire.A collection form for medical family history data that can be printed and used in clinical practice. This tool cannot accurately calculate risk for women with a medical history of breast cancer, DCIS or LCIS. One way to gather information is to use ASCO’s Family Cancer History questionnaire. Myriad's Family History Tool is not supported by your current browser. We recommend discussing your results with a healthcare provider. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. If you do not know much about your family history, do the best you can. This simple, 30-second quiz can help you get the information you need to discuss your risk of cancer with your healthcare professional and ask for further evaluation. Personal and Family History Questionnaire It is very important for you to complete this form to the best of your ability and return it well in advance of your scheduled appointment.This allows us appropriate time to prepare, so the consultation is as beneficial as possible. Emphasizing to your patients the importance of capturing a thorough family history will allow you to better evaluate their hereditary cancer risk and appropriateness for testing. If you do not know the exact date of birth and/ or death, or where a person was treated, INSTRUCTIONS: Your family history is important. Do you haveTWO close relativeson the same side of the family diagnosed with colon, endometrial (uterine), or ovarian cancer, one at AGE 50 OR YOUNGER? If your family Y ) for those that apply to you and/or your family or because or. 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