Risk Assessment For Hereditary Cancer Syndromes Questionnaire
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1Risk Assessment for Hereditary Cancer Syndromes
Patient Name: ________________________Date of Birth: _____________ Date __________ Insurance Carrier__________
Women’s Clinic of Northern Colorado is dedicated to improving your quality of care, committed to your health, and
helping with cancer prevention. To best serve you, we need a detailed personal and family cancer history.
Please consider the following Family Members when completing this form: (Blood Relatives Only)
st
Mother, Father, Sister, Brother, Children: (1
degree relatives)
nd
Aunt, Uncle, Grandmother, Grandfather, Grandchild, Niece, Nephew, Half Siblings: (2
degree relatives)
rd
Cousins, Great Grandparent, Great Aunt, Great Uncle: (3
degree relatives)
YOUR FAMILY’S Cancer History
(Please be thorough and accurate. Please include BIOLOGICAL FAMILY ONLY)
YOU
PARENTS / SIBLINGS /
CANCER
AGE
MOTHER’S SIDE
AGE
FATHER’S SIDE
AGE
(age)
CHILDREN
Y
EXAMPLE: BREAST
45
Aunt
Sister
41
Grandmother
53
N
CANCER
Cousin
61
BREAST CANCER
Y
N
OVARIAN CANCER
Y
N
COLON/RECTAL CANCER
Y
N
UTERINE/ENDOMETRIAL
Y
CANCER
N
OTHER CANCER(S)
Y
(SPECIFY):
N
Y
N
Are you of Jewish descent?
What is your Ancestry:_______________________
Y
N
Have you or anyone in your family had genetic testing for a hereditary cancer syndrome? If yes, please explain:
Cancer Risk Assessment Review and Counseling
Patient’s Signature:_________________________________________________________________ Date: _____________________
Health Care Provider’s Signature: _____________________________________________________ Date: _____________________
For Office Use Only: Patient offered hereditary cancer genetic testing?
YES
NO
ACCEPTED
DECLINED (patient signature below)
Informed Refusal Documentation
My provider, has recommended the BRACAnaylsis and/or Colaris and/or myRISK genetic test based on my personal
and/or family history of cancer. He/She has explained to me the potential benefits of the genetic test and the risks of
not consenting to the genetic test. Despite my provider’s recommendation, I decline to consent to the genetic test.
Signature of patient for informed refusal_______________________________________________________
For Office Use Only:
Hereditary Breast and Ovarian Cancer Syndrome
Lynch Syndrome
Breast cancer diagnosed at or under age 45*
1 Colon, rectal or uterine cancer diagnosed at or under age 50*
Ovarian cancer at any age*
2 or more w/ a Lynch syndrome cancer****, 1 before the age of 50 and 1 being
colon, rectal or uterine cancer**
2 primary breast cancers in the same person w/ 1 diagnosed at or under age
50**
3 or more w/ a Lynch syndrome cancer**** at any age and one being colon, rectal
or uterine cancer**
2 relatives same side of the family w/ breast cancer, 1 diagnosed at or under
age 50**
st
nd
*Self, 1
, 2
degree family members
3 or more of the following cancers at any age on the same side of the family:
st
nd
rd
**Self, 1
, 2
, or 3
degree family members
breast, ovarian, pancreatic, prostate**
***HBOC associated cancers: Breast, ovarian, pancreatic
Triple negative breast cancer at or under the age of 60*
****Lynch associated cancers: Colon, uterine, gastric, ovarian, ureter/renal pelvis,
Male breast cancer*
biliary tract, small bowel, pancreas, brain, sebaceous adenomas
Ashkenazi Jewish ancestry with an HBOC*** associated cancer*
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