Family History Form
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5FAMILY HISTORY FORM
The Hereditary Cancer Program at Washington University School of Medicine
Please complete this form as best you are able. Contact us at 314-286-0688 with any questions.
Your family cancer history and your personal health history are used to determine your cancer risk
and/or chance your family has hereditary cancer. Knowing your extended family history helps to
provide a better estimation of your risk.
The following pages contain a sample family cancer history, a blank form for you to complete your
family history, and a table to document your family members’ names and medical conditions. The
family history form and family history table are linked to one another.
Ask the following questions for family members who have been diagnosed with cancer:
Where did the cancer start, or, what was the specific cancer type (for example, colon cancer)?
About what age was the person diagnosed?
Did the family member have more than one type of cancer? Do not include a cancer that
spread to another part of the body.
Did any family member have genetic testing? What gene(s) was tested and what were the
specific results? Will your family member share a copy of the genetic testing results?
Instructions for completing your family history form –
SEE SAMPLE FAMILY HISTORY
Circles stand for females and squares stand for males.
Start at the bottom of the form and draw a circle or a square for yourself.
Add your sisters and brothers along the connecting line, next to you, using circles to designate
females and squares for males.
Children are drawn on lines directly below their parents. Remember to include your children.
Take the same steps for your mother’s siblings and your father’s siblings. Include your cousins.
Do the same thing for your grandparents and their siblings, if you know this information.
Instructions for completing the family history table
List your family members on the family history table including any cancer diagnosis or other
important medical illnesses.
Give yourself the number 1 on the table.
Each family member should have his or her own number.
Write the family member’s name next to the number on the table.
Write the family member’s cancer diagnosis or other important medical conditions.
If the family member is deceased, write the approximate age at death and cause of death, if
you have this information.
Questions?
Contact us with any questions, 314-286-0688.
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