Family History Questionnaire For Common Hereditary Cancer Syndromes Template
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Women's Health Partners, LLC
Family History Questionnaire for Common Hereditary Cancer Syndromes
Name:
Instructions: Please circle "Y" to those that apply to YOU and/or YOUR FAMILY (on both your mother's or father's side). Behind each
statement, please list the relationship to you of the individual diagnosed (such as self, paternal uncle, maternal aunt, paternal
grandmother) and their age at diagnosis. Each statement should be answered individually, so you may list the same cancer diagnosis
more than once as you answer these questions.
BREAST AND OVARIAN CANCER
Yes
No
RELATIONSHIP
AGE AT DIAGNOSIS
- Breast cancer before 50
- Ovarian cancer
- Breast cancer in both breast or multiple
primary breast cancers
- Both breast & ovarian cancer
(in an individual or family)
- Male breast cancer
- 2 or more breast or ovarian cancers
(in an individual or family)
- Ashkenazi Jewish ancestry & personal or
family history of breast or ovarian cancer
COLON AND UTERINE CANCER
Yes
No
RELATIONSHIP
AGE AT DIAGNOSIS
- Uterine cancer before 50
- Colorectal cancer before 50
- Both uterine & colorectal cancer
(in an individual or family)
- 2 or more uterine or colorectal cancers
(in an individual or family)
- Uterine and/or colorectal cancer AND
ovarian, stomach, kidney/urinary tract, brain
or small bowel cancer
(in an individual or family)
COLON POLYP HISTORY
RELATIONSHIP
AGE AT DIAGNOSIS
Yes
No
- 10 or more colon polyps found in lifetime
WHP PATIENT REGISTRATION rev. 11/10
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