Genetic Counseling Personal and Family History Questionnaire...Genetic Counseling Personal and Family History Questionnaire We are looking forward to your upcoming visit with us. We

Genetic Counseling Personal and Family History Questionnaire

We are looking forward to your upcoming visit with us. We want to present you with a complete plan of care - tailored just for you. Please complete this form and return it ten (10) to fifteen (15) days before your visit. The information gathered from the Personal and Family Health Questionnaire will enable our genetic counselors to prepare for your visit.

Please Return Your Completed Form To:

Rocky Mountain Cancer Centers – Genetic Counseling Department Mail: FAX: 303-930-8060EMAIL: [email protected]

*If you have questions we would love to answer them. Please call us at 303-930-7837

Section 1: Tell Us About Yourself

Last Name First Name M.I. Date of Birth Sex

Male Female

Transgender

Have you had any genetic testing? Yes No Unsure

Are either of your parents of Ashkenazi Jewish descent? Mother: Yes No Unsure Father: Yes No Unsure

What do you consider to be your racial background (check all that apply)

African American Asian Hispanic Native American/Native Alaskan Native Hawaiian/Other Pacific Islander

Multi-racial Other White

What is your mother’s ethnic background? (such as German, Dominican Republic, Nigerian, French Canadian, etc)

What is your father’s ethnic background? (such as German, Dominican Republic, Nigerian, French Canadian, etc)

mailto:[email protected]

Have any of your family members had genetic testing? Yes No Unsure

Have you ever had a colonoscopy/sigmoidoscopy?

If yes, were any polyps removed?

Yes No

Yes No Have you ever had a breast biopsy? Yes No How many?

Have you been diagnosed with cancer? Check all that apply: Age at diagnosis: Breast Colon Uterine Other

Section 2: Women Please Complete this Section

At what age did you begin your period?

Have you gone through menopause? Yes No Currently

How old were you when your first child was born?

Have you had a hysterectomy?

Have you had your ovaries removed?

Yes No

Yes No

Have you ever taken hormone replacement therapy (HRT)? If yes, please answer the following:

Estrogen Only Yes No Unsure Estrogen and Progesterone Yes No Unsure Length of use less than 1 year 1-4 5-10 over 10

Yes No Unsure

Have you taken oral contraceptives (the pill)?

If yes, length of use

Less than 1 year 1-4 5-10 Over 10

Yes No

Section 3: Your Parents and Grandparents Your family’s medical history is an important piece of your medical story. The family history questions below ask for details about your family that you may not know, or be comfortable sharing and that’s okay. Please know we are asking these questions so that we can identify any family trends, evaluate your risk for cancer (or future cancers) and to prepare a personal medical management program for you. *If you are adopted or do not know your biological family history you may skip this section.

Parents and Grandparents

If Alive: Current Age

If Deceased: Age at Death

Diagnosed with Cancer? Age at Cancer Diagnosis

Any History of Benign or Pre-cancerous Growths

Mother Yes No

Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify) Unsure

Colon Polyps Uterine Fibroids Goiter/Thyroid Nodules Other (specify) Unsure

Father Yes No

Kind of cancer (check all that apply) Breast Colon Other (specify) Unsure

Colon Polyps Goiter/Thyroid Nodules Other (specify) Unsure

Your Father’s Father

Yes No



Your Father’s Mother

Yes No



Your Mother’s Father

Yes No



Your Mother’s Mother

Yes No



Section 4: Your Siblings

First name:

Full or Half Sibling (check box)



Diagnosed with Cancer Age at Cancer Diagnosis


Full Half sib

thru mom Half sib

thru dad

Yes No

Kind of cancer (check all that apply)

Breast Colon Ovarian Other (specify) Unsure

Colon Polyps Uterine Fibroids

Goiter/Thyroid Nodules Other (specify) Unsure

Full Half sib

thru mom Half sib

thru dad

Yes No




Full Half sib

thru mom Half sib

thru dad

Yes No




Full Half sib

thru mom Half sib

thru dad

Yes No





Section 5: Your Children

First name:

Male or Female





Male Female

No Yes





Male Female

Yes No




Male Female

Yes No




Male Female

Yes No




(Continued)

Your Aunts/ Uncles on MOTHER’S Side:

Aunt/Uncle If Alive: Current Age




Aunt Uncle

Yes No



Goiter/Thyroid Nodules Other (specify)

Unsure

Section 5: Your Children First name:

Male or Female





Section 6: Extended Family (Only List Those Who Have or Had Cancer)

Aunt Uncle

Yes No



Aunt Uncle

Yes No



Section 6: Continued

Aunts/Uncles on your FATHER’S Side:

Aunt/Uncle If Alive: Current Age




Aunt Uncle

Yes No



Aunt Uncle

Yes No



Aunt Uncle

Yes No



Aunt Uncle

Yes No



Section 7: Your Nieces/Nephews with Cancer

First name:

Male or Female If Alive: Current Age




Male Female

Yes No

Kind of cancer (check all that apply) Breast Colon Ovarian Other (specify)

Unsure


Male Female

Yes No



Male Female

Yes No



Section 8 : List Any Other Relatives with Cancer

Relation to you:

What Side of the Family





Maternal Paternal

Yes No



Maternal Paternal

Yes No



Authorization to Disclose My Genetic Consultation and Genetic Test Results

Patient Name: ______________________________________Date of Birth:___________

I authorize for Rocky Mountain Cancer Centers to disclose genetic consultation notes and genetic test results to the following physicians or persons:

1._____________________________________________________________________

2._____________________________________________________________________

3.______________________________________________________________________

4.______________________________________________________________________

This authorization ends one year following the date at which it is signed unless otherwise noted here:___________________________________________.

_______________________________________ ______________________ Patient or legally authorized individual signature Date

_______________________________________________ ___________________________________ Printed name if signed on behalf of the patient Relationship(parent, guardian, personal

representative, etc)


Rocky Mountain Cancer Centers – Genetic Counseling Department Mail: FAX: 303-930-8060 EMAIL: [email protected]

Authorization to Disclose My Genetic Consultation andGenetic Test Results

Patient Name: ______________________________________Date of Birth:___________

I authorize for Rocky Mountain Cancer Centers to disclose genetic consultation notes andgenetic test results to the following physicians or persons:

1._____________________________________________________________________

2._____________________________________________________________________

3.______________________________________________________________________

4.______________________________________________________________________

This authorization ends one year following the date at which it is signed unless otherwise noted here:___________________________________________.

_______________________________________ ______________________ Patient or legally authorized individual signature Date

_______________________________________________ ___________________________________ Printed name if signed on behalf of the patient Relationship(parent, guardian, personal

representative, etc)


Rocky Mountain Cancer Centers – Genetic Counseling DepartmentMail: 4700 E. Hale Parkway, Suite 400, Denver, CO 80220FAX: 303-930-8060EMAIL: [email protected]

Patient or legally authorized individual signature. By typing your name in the box, below, you are authorizing the disclosure of your results.

mailto:[email protected]

Documents

Genetic Counseling Personal and Family History Questionnaire...Genetic Counseling Personal and Family History Questionnaire We are looking forward to your upcoming visit with us. We