Genetic Counseling Personal and Family History Questionnaire...Genetic Counseling Personal and...
Transcript of Genetic Counseling Personal and Family History Questionnaire...Genetic Counseling Personal and...
Genetic Counseling Personal and Family History Questionnaire
We are looking forward to your upcoming visit with us. We want to present you with a complete plan of care - tailored just for you. Please complete this form and return it ten (10) to fifteen (15) days before your visit. The information gathered from the Personal and Family Health Questionnaire will enable our genetic counselors to prepare for your visit.
Please Return Your Completed Form To:
Rocky Mountain Cancer Centers – Genetic Counseling Department Mail: FAX: 303-930-8060EMAIL: [email protected]
*If you have questions we would love to answer them. Please call us at 303-930-7837
Section 1: Tell Us About Yourself
Last Name First Name M.I. Date of Birth Sex
Male Female
Transgender
Have you had any genetic testing? Yes No Unsure
Are either of your parents of Ashkenazi Jewish descent? Mother: Yes No Unsure Father: Yes No Unsure
What do you consider to be your racial background (check all that apply)
African American Asian Hispanic Native American/Native Alaskan Native Hawaiian/Other Pacific Islander
Multi-racial Other White
What is your mother’s ethnic background? (such as German, Dominican Republic, Nigerian, French Canadian, etc)
What is your father’s ethnic background? (such as German, Dominican Republic, Nigerian, French Canadian, etc)
Have any of your family members had genetic testing? Yes No Unsure
Have you ever had a colonoscopy/sigmoidoscopy?
If yes, were any polyps removed?
Yes No
Yes No Have you ever had a breast biopsy? Yes No How many?
Have you been diagnosed with cancer? Check all that apply: Age at diagnosis: Breast Colon Uterine Other
Section 2: Women Please Complete this Section
At what age did you begin your period?
Have you gone through menopause? Yes No Currently
How old were you when your first child was born?
Have you had a hysterectomy?
Have you had your ovaries removed?
Yes No
Yes No
Have you ever taken hormone replacement therapy (HRT)? If yes, please answer the following:
Estrogen Only Yes No Unsure Estrogen and Progesterone Yes No Unsure Length of use less than 1 year 1-4 5-10 over 10
Yes No Unsure
Have you taken oral contraceptives (the pill)?
If yes, length of use
Less than 1 year 1-4 5-10 Over 10
Yes No
Section 3: Your Parents and Grandparents Your family’s medical history is an important piece of your medical story. The family history questions below ask for details about your family that you may not know, or be comfortable sharing and that’s okay. Please know we are asking these questions so that we can identify any family trends, evaluate your risk for cancer (or future cancers) and to prepare a personal medical management program for you. *If you are adopted or do not know your biological family history you may skip this section.
Parents and Grandparents
If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer? Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Mother Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Father Yes No
Kind of cancer (check all that apply) Breast Colon Other (specify) Unsure
Colon Polyps Goiter/Thyroid Nodules Other (specify) Unsure
Your Father’s Father
Yes No
Kind of cancer (check all that apply) Breast Colon Other (specify) Unsure
Colon Polyps Goiter/Thyroid Nodules Other (specify) Unsure
Your Father’s Mother
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Your Mother’s Father
Yes No
Kind of cancer (check all that apply) Breast Colon Other (specify) Unsure
Colon Polyps Goiter/Thyroid Nodules Other (specify) Unsure
Your Mother’s Mother
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Section 4: Your Siblings
First name:
Full or Half Sibling (check box)
If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Full Half sib
thru mom Half sib
thru dad
Yes No
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids
Goiter/Thyroid Nodules Other (specify) Unsure
Full Half sib
thru mom Half sib
thru dad
Yes No
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Full Half sib
thru mom Half sib
thru dad
Yes No
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Full Half sib
thru mom Half sib
thru dad
Yes No
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids
Goiter/Thyroid Nodules Other (specify) Unsure
Section 5: Your Children
First name:
Male or Female
If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Male Female
No Yes
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids
Goiter/Thyroid Nodules Other (specify) Unsure
Male Female
Yes No
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Male Female
Yes No
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Male Female
Yes No
Kind of cancer (check all that apply)
Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
(Continued)
Your Aunts/ Uncles on MOTHER’S Side:
Aunt/Uncle If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Aunt Uncle
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids
Goiter/Thyroid Nodules Other (specify)
Unsure
Section 5: Your Children First name:
Male or Female
If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Section 6: Extended Family (Only List Those Who Have or Had Cancer)
Aunt Uncle
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Aunt Uncle
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Section 6: Continued
Aunts/Uncles on your FATHER’S Side:
Aunt/Uncle If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Aunt Uncle
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Aunt Uncle
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Aunt Uncle
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Aunt Uncle
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Section 7: Your Nieces/Nephews with Cancer
First name:
Male or Female If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Male Female
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify)
Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Male Female
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Male Female
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Section 8 : List Any Other Relatives with Cancer
Relation to you:
What Side of the Family
If Alive: Current Age
If Deceased: Age at Death
Diagnosed with Cancer Age at Cancer Diagnosis
Any History of Benign or Pre-cancerous Growths
Maternal Paternal
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Maternal Paternal
Yes No
Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure
Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure
Authorization to Disclose My Genetic Consultation and Genetic Test Results
Patient Name: ______________________________________Date of Birth:___________
I authorize for Rocky Mountain Cancer Centers to disclose genetic consultation notes and genetic test results to the following physicians or persons:
1._____________________________________________________________________
2._____________________________________________________________________
3.______________________________________________________________________
4.______________________________________________________________________
This authorization ends one year following the date at which it is signed unless otherwise noted here:___________________________________________.
_______________________________________ ______________________ Patient or legally authorized individual signature Date
_______________________________________________ ___________________________________ Printed name if signed on behalf of the patient Relationship(parent, guardian, personal
representative, etc)
Please Return Your Completed Form To:
Rocky Mountain Cancer Centers – Genetic Counseling Department Mail: FAX: 303-930-8060 EMAIL: [email protected]
Authorization to Disclose My Genetic Consultation andGenetic Test Results
Patient Name: ______________________________________Date of Birth:___________
I authorize for Rocky Mountain Cancer Centers to disclose genetic consultation notes andgenetic test results to the following physicians or persons:
1._____________________________________________________________________
2._____________________________________________________________________
3.______________________________________________________________________
4.______________________________________________________________________
This authorization ends one year following the date at which it is signed unless otherwise noted here:___________________________________________.
_______________________________________ ______________________ Patient or legally authorized individual signature Date
_______________________________________________ ___________________________________ Printed name if signed on behalf of the patient Relationship(parent, guardian, personal
representative, etc)
Please Return Your Completed Form To:
Rocky Mountain Cancer Centers – Genetic Counseling DepartmentMail: 4700 E. Hale Parkway, Suite 400, Denver, CO 80220FAX: 303-930-8060EMAIL: [email protected]
Patient or legally authorized individual signature. By typing your name in the box, below, you are authorizing the disclosure of your results.