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 2. 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 Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. 100 0 obj <>stream 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. This is important in assessing your cancer risk. Title: Microsoft Word - Myriad Cancer Family History Questionnaire_PMRC Approved_1101612.docx Author: jbennett Created Date: 11/16/2012 10:57:46 AM The scgsquestionnaire collected data about cancer history for both the patient and the patient’s family. If you do not know the exact date of birth and/ or death, or where a person was treated, This is a screening questionnaire for the common features of hereditary cancers. The field deals with the role of genes and heredity in the health and well-being of a person. 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. 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. The medical significance of tracking the family genogramcame to light with the developments in medical genetics. Myriad's Family History Tool is not supported by your current browser. 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. 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. Cancer History Questionnaire To assess your personal hereditary cancer risk, please complete the questionnaire below and return it to your healthcare provider. 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 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. 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. Please include cancers from both your biological maternal (mother’s) and paternal (father’s) sides of your family, when completing the answers. 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. Personal Information. If yes, then indicate family %PDF-1.5 %���� CANCER FAMILY HISTORY QUESTIONNAIRE. Completing this questionnaire will help us to determine the risk of a hereditary cancer predisposition in your family. You should also send the form to your close relatives so they have the information to … Myriad's Family Cancer History Tool. This tool cannot accurately calculate risk for women with a medical history of breast cancer, DCIS or LCIS. Childhood Medulloblastoma - Family Cancer History questionnaire ¦¦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. 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�&� 7 0 obj <> endobj 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. This may be because there are several cancers in your family or because you or a relative has had cancer at a young age. Determine if myriad myRisk® hereditary cancer predisposition in your family is very,... Outlines common inheritance patterns of conditions with an underlying genetic component write in your guess. ) for those that apply to you and/or your family is very,. 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