"Hereditary Cancer Syndrome Risk Assessment Form"

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Hereditary Cancer Syndrome Risk Assessment
Patient Name: ________________________________ Physician:
______________________
Date of Birth: _________________________________ Date Completed:
______________________
This is a screening tool for the common features of Hereditary Breast and Ovarian Cancer Syndrome and Lynch Syndrome.
Instruction:
Please circle Y for those that apply to YOU and/or YOUR FAMILY (on both your mothers or fathers side).
Each statement should be answered individually, so you may list the same cancer diagnosis more than once.
You and the following family member should be considered:
Mother, Father, Brother, Sister, Children, Nieces/Nephews
Maternal – Grandmother, Grandfather, Aunts, Uncles, First Cousins
Paternal - Grandmother, Grandfather, Aunts, Uncles, First Cousins
Y
N
Have you ever been tested for hereditary risk of cancer (BRCA testing or Lynch Syndrome Testing)? If yes, please explain:
Have any members of your family ever been tested for hereditary risk of cancer (BRCA testing or Lynch Syndrome Testing)?
Y
N
If yes, please explain:
BREAST AND OVARIAN CANCER
SELF
FAMILY MEMBER AGE AT DIAGNOSIS
Ashkenazi Jewish ancestry with breast or ovarian cancer
Y
N
diagnosed in you or any family member?
Y
N
Ovarian cancer diagnosed in you or any family members?
Y
N
Male breast cancer diagnosed in any family members?
Breast cancer diagnosed at 45 years of age or younger in
Y
N
you or any family members?
Y
N
Bilateral breast cancer or multiple primary breast cancers
diagnosed in you or any family members?
Y
N
Three or more breast cancers diagnosed all on the same
side of your family?
Pancreatic cancer with breast or ovarian cancer in the
Y
N
same person or on the same side of the family?
COLON AND UTERINE CANCER
SELF
FAMILY MEMBER AGE AT DIAGNOSIS
Y
N
Colon cancer diagnosed before 50 years of age in you or
any family members?
Y
N
Uterine (Endometrial) cancer diagnosed before 50 years
of age in you or any family members?
Two or more of the following cancers diagnosed all on the
Y
N
same side of your family(
colon, uterine, ovarian, stomach, small
Bowel, kidney/urinary tract, pancreatic, or brain)
For Office Use Only
Patient offered genetic testing
________________________
Accepted
Declined
Reviewed By:
Patient Signature __________________________________________________________________
Shared (//parkwest5/west) (H) Chart Forms 2/2016
Hereditary Cancer Syndrome Risk Assessment
Patient Name: ________________________________ Physician:
______________________
Date of Birth: _________________________________ Date Completed:
______________________
This is a screening tool for the common features of Hereditary Breast and Ovarian Cancer Syndrome and Lynch Syndrome.
Instruction:
Please circle Y for those that apply to YOU and/or YOUR FAMILY (on both your mothers or fathers side).
Each statement should be answered individually, so you may list the same cancer diagnosis more than once.
You and the following family member should be considered:
Mother, Father, Brother, Sister, Children, Nieces/Nephews
Maternal – Grandmother, Grandfather, Aunts, Uncles, First Cousins
Paternal - Grandmother, Grandfather, Aunts, Uncles, First Cousins
Y
N
Have you ever been tested for hereditary risk of cancer (BRCA testing or Lynch Syndrome Testing)? If yes, please explain:
Have any members of your family ever been tested for hereditary risk of cancer (BRCA testing or Lynch Syndrome Testing)?
Y
N
If yes, please explain:
BREAST AND OVARIAN CANCER
SELF
FAMILY MEMBER AGE AT DIAGNOSIS
Ashkenazi Jewish ancestry with breast or ovarian cancer
Y
N
diagnosed in you or any family member?
Y
N
Ovarian cancer diagnosed in you or any family members?
Y
N
Male breast cancer diagnosed in any family members?
Breast cancer diagnosed at 45 years of age or younger in
Y
N
you or any family members?
Y
N
Bilateral breast cancer or multiple primary breast cancers
diagnosed in you or any family members?
Y
N
Three or more breast cancers diagnosed all on the same
side of your family?
Pancreatic cancer with breast or ovarian cancer in the
Y
N
same person or on the same side of the family?
COLON AND UTERINE CANCER
SELF
FAMILY MEMBER AGE AT DIAGNOSIS
Y
N
Colon cancer diagnosed before 50 years of age in you or
any family members?
Y
N
Uterine (Endometrial) cancer diagnosed before 50 years
of age in you or any family members?
Two or more of the following cancers diagnosed all on the
Y
N
same side of your family(
colon, uterine, ovarian, stomach, small
Bowel, kidney/urinary tract, pancreatic, or brain)
For Office Use Only
Patient offered genetic testing
________________________
Accepted
Declined
Reviewed By:
Patient Signature __________________________________________________________________
Shared (//parkwest5/west) (H) Chart Forms 2/2016