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 . 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. Provides tips, resources, and tools for family history collection in clinical practice. Childhood Medulloblastoma - Family Cancer History questionnaire INSTRUCTIONS: Your family history is important. 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 should also send the form to your close relatives so they have the information to … 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 This questionnaire is designed for the most common types of hereditary cancer and not appropriate for the assessment of rare syndromes. 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. If you do not know much about your family history, do the best you can. 5. h��Xmo�8�+������ Xp���]����f�>���kK>I�m���)�/�ǻ��D����ea�h�1�p���D0O�#�Ib. CANCER FAMILY HISTORY QUESTIONNAIRE. 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. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. Instructions: This is a screening tool to determine if Myriad myRisk® Hereditary Cancer testing is right for you. Family History Questionnaire.A collection form for medical family history data that can be printed and used in clinical practice. Next to each statement, please list the relationship(s) to you and age of diagnosis for each … Warning! If you are uncertain about any information, please write in your best guess or write unknown. 3. Myriad's Family Cancer History Tool. Save time, reduce the cost of care, and improve outcomes by catching cancer early … This tool cannot accurately calculate risk for women with a medical history of breast cancer, DCIS or LCIS. 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. One way to gather information is to use ASCO’s Family Cancer History questionnaire. 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�&� The field deals with the role of genes and heredity in the health and well-being of a person. 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. You may find it helpful to contact other family members to get information about more distant relatives. Because these diseases are … Leverage genetics and family history to identify and manage patients at high risk for cancer. Helps identify red flag… Cancer Genetics Family History Questionnaire . PERSONAL INFORMATION . ¦¦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. 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. Biological Family History: Please fill out the following information where it applies to your biological family only. Please include cancers from both your biological maternal (mother’s) and paternal (father’s) sides of your family, when completing the answers. If you do not know the exact date of birth and/ or death, or where a person was treated, 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 Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. These questions are based on the clinical guidelines doctors use to determine whether you should be tested for one of the above syndromes. 4. 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. 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? 7 0 obj <> endobj 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. 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 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 Please answer these questions as completely as possible. 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. 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. 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 %PDF-1.5 %���� We recommend discussing your results with a healthcare provider. Cancer Family History Questionnaire. 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. This is a screening questionnaire for the common features of hereditary cancers. For people with disabilities, this document is available on request in other formats. 2. Patient Name Date of Birth Age Gender (M/F) Today’s Date (MM/DD/YYYY) Health Care Provider . Oregon Health & Science University – Knight Cancer Institute . 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. Myriad's Family History Tool is not supported by your current browser. Pedigree Tool.A template to record a pedigree with standard pedigree nomenclature. Title: Microsoft Word - Myriad Cancer Family History Questionnaire_PMRC Approved_1101612.docx Author: jbennett Created Date: 11/16/2012 10:57:46 AM 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. Inheritance Patterns Factsheet. Take the Quiz. Why have I been given a family history questionnaire? endstream endobj startxref List ALL family members, including those with and without cancer. %%EOF Myriad Genetics’ Hereditary Cancer Quiz helps you to assess whether you might be a good candidate for genetic testing. 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. 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. This is important in assessing your cancer risk. Completing this questionnaire will help us to determine the risk of a hereditary cancer predisposition in your family. This is a graphical version of the Sample Cancer Family History Questionnaire. The medical significance of tracking the family genogramcame to light with the developments in medical genetics. Family History Questionnaire. The scgsquestionnaire collected data about cancer history for both the patient and the patient’s family. 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. 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. Cancer Risk Assessment Tool. 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. To submit a request, please call 1-800-525-0127 (TDD/TTY call 711). This questionnaire has been developed as a general family history collection tool. If you take the quiz and find red flags in your own or your family’s health history, you may benefit from hereditary … This may be because there are several cancers in your family or because you or a relative has had cancer at a young age. 0 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. 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 If yes, then indicate family Family History Collection Tips & Tools. If your family is very large, you may photocopy or add more sheets of paper. See Other Risk Assessment Tools for more information. 100 0 obj <>stream It is concerned with disorders that can be transmitted from the parent to offspring and succeeding generation. Cancer Family History Questionnaire. Personal Information. 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