Cancer Risk Assesment Form

Provide two answers: 1. maternal ethnicity 2. paternal ethnicity ( please label what belongs to each side)

List each child by name and age. Include any deceased, and age at death.

also, the name of child, age of onset or cancer, and cancer type.

If yes, what type? How many years ago or are you still using?

NA Less than 1 year 1 year 2 years 3 years 4 years 5 or more years

If yes, list organ and age when removed (ex: uterus removed at age 30, only right ovary and fallopian tube removed,)

Please list results of each biopsy? (normal/abnormal/ atypical hyperplasia)

Explain and provide any pathology information that you know about.

Age now. If deceased, list age at death.

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.

Any information on cancer type, age of diagnosis, and age of death. Any information on grandparent's siblings.

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.

Please also include your biological half-brother(s)
(eg. Rob-42, Joe-40, Steve, half-brother-39)

Please also include your biological half-sister(s)
(eg. Mary-45, Alice-43, Jen, half-sister-40)

Also list age at diagnosis and current age.

(eg. Brother Steve diagnosed with testicular cancer at 32, now 40)

List the name of their parent and age at diagnosis.

(eg. Steve's daughter had breast cancer at 23)

(eg. Mike-70, Cecelia-68, Joan-65)

(eg. Mel-62, Joseph-59, Sheila-55)

List side of family, name, type of cancer and age at diagnosis.

(eg. Maternal aunt Sheila, endometrial cancer at 30)

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.

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?

(eg. I smoked a pack of cigarettes a day from age 20 to 40 but quit ten years ago.)

Please list any other relatives with breast or ovarian cancer that you may not have already mentioned.

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.

Your Code
Enter Code

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)

7. Age

8. Weight (lbs. and oz.)

9. Height (ft. and in.)

10. Gender

11. Ethnicity (eg: Ashkenazi Jewish, French, American Indian, etc.)

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)

21. Please note whether any children had cancer

22. Have you entered menopause? At what age?

23. Have you ever used hormonal therapy?

24. Duration of hormonal therapy?

25. Have you ever had surgery to remove any organs?

26. Have you ever had tubal ligation? (yes/no)

27. Breast biopsy information

28. List any cancers you have had, type and age of diagnosis

29. Have you been diagnosed with any precancerous conditions?

30. Hospitalization History/Medical Conditions (List year(s) and reason(s)

31. Please list the ages of your parents

32. Cancer History Information on Parents

33. Did either of your paternal grandparents have cancer or die young?

34. Did either of your maternal grandparents have cancer or die young?

35. List all your brother(s) by first name and age

36. List all your sister(s) by first name and age

37. Do any of your brothers and/or sisters have cancer? If yes, who?

38. Do any of your nieces or nephews have cancer?

39. List your mother's brothers and sisters and ages

40. List your father's brothers and sisters and ages

41. Do any of your aunts or uncles have cancer? Who?

42. Do any of your cousins have cancer? If yes, who?

43. List any relatives who died at a young age

44. Have you ever been exposed to excessive radiation or x-rays?

45. Please discuss your alcohol and smoking history.

46. Please list any additional information you feel may be useful to us

47. Verifier