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For Genetic Counselors
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Clients without computer access may contact us by phone at 888-260-6543
Forms must be completed/ submitted prior to leaving our website
1. Today's Date (Month/Day/Year)
2. What is your reason for obtaining genetic information?
3. Have you or any relative had cancer genetic testing? Explain.
4. First Name, M.I.
5. Last Name
6. Date of Birth (Month/Day/Year)
8. Weight (lbs. and oz.)
9. Height (ft. and in.)
11. Ethnicity (eg: Ashkenazi Jewish, French, American Indian, etc.)
Provide two answers: 1. maternal ethnicity 2. paternal ethnicity ( please label what belongs to each side)
12. Day Phone
13. Religion (eg: Roman Catholic, Jewish, etc.)
14. Evening Phone
15. Highest level of education completed
16. Marital Status
17. Age at onset of menstrual cycles
18. Have you ever given birth?
19. Age when you first gave birth
20. List all of your biological children and ages (including any deceased)
List each child by name and age. Include any deceased, and age at death.
21. Please note whether any children had cancer
also, the name of child, age of onset or cancer, and cancer type.
22. Have you entered menopause? At what age?
23. Have you ever used hormonal therapy?
If yes, what type? How many years ago or are you still using?
24. Duration of hormonal therapy?
NA Less than 1 year 1 year 2 years 3 years 4 years 5 or more years
25. Have you ever had surgery to remove any organs?
If yes, list organ and age when removed (ex: uterus removed at age 30, only right ovary and fallopian tube removed,)
26. Have you ever had tubal ligation? (yes/no)
27. Breast biopsy information
Please list results of each biopsy? (normal/abnormal/ atypical hyperplasia)
28. List any cancers you have had, type and age of diagnosis
29. Have you been diagnosed with any precancerous conditions?
Explain and provide any pathology information that you know about.
30. Hospitalization History/Medical Conditions (List year(s) and reason(s)
31. Please list the ages of your parents
Age now. If deceased, list age at death.
32. Cancer History Information on Parents
Please tell us about any type of cancer and age of onset. Remember to include multiple cancers and onset information on those. If you are aware of breast cancer being bilateral or 'triple negative', please tell us.
33. Did either of your paternal grandparents have cancer or die young?
Any information on cancer type, age of diagnosis, and age of death. Any information on grandparent's siblings.
34. Did either of your maternal grandparents have cancer or die young?
If it applies, provide any information on cancer type, age of diagnosis, age or approximate age of death and cause of death. Also, if you know the same about any of their siblings, please describe here.
35. List all your brother(s) by first name and age
Please also include your biological half-brother(s)
(eg. Rob-42, Joe-40, Steve, half-brother-39)
36. List all your sister(s) by first name and age
Please also include your biological half-sister(s)
(eg. Mary-45, Alice-43, Jen, half-sister-40)
37. Do any of your brothers and/or sisters have cancer? If yes, who?
Also list age at diagnosis and current age.
(eg. Brother Steve diagnosed with testicular cancer at 32, now 40)
38. Do any of your nieces or nephews have cancer?
List the name of their parent and age at diagnosis.
(eg. Steve's daughter had breast cancer at 23)
39. List your mother's brothers and sisters and ages
(eg. Mike-70, Cecelia-68, Joan-65)
40. List your father's brothers and sisters and ages
(eg. Mel-62, Joseph-59, Sheila-55)
41. Do any of your aunts or uncles have cancer? Who?
List side of family, name, type of cancer and age at diagnosis.
(eg. Maternal aunt Sheila, endometrial cancer at 30)
42. Do any of your cousins have cancer? If yes, who?
Provide first name of cousin, and of parent, so that we can make the correct link on your pedigree. List cancer and age of diagnosis.
eg. my cousin Joe, son of aunt Mary was diagnosed with colon cancer at age 24, he is now age 30.
43. List any relatives who died at a young age
Please consider brothers or sisters of your grandparents, or more distant relatives, describing as best as you can how they may be related to you. Also anything else you know about their health history?
44. Have you ever been exposed to excessive radiation or x-rays?
45. Please discuss your alcohol and smoking history.
(eg. I smoked a pack of cigarettes a day from age 20 to 40 but quit ten years ago.)
46. Please list any additional information you feel may be useful to us
Please list any other relatives with breast or ovarian cancer that you may not have already mentioned.
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