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We need information on both of your parents. Tell us as much as you know. ( Example: My mother relatives are Mexican and my father's family is mixed, with his father being African American and his mother being Ashkenazi Jewish).

Include deceased children.

(ex: ovarian cancer at 44, endometrial cancer at 50, skin cancer at 58)

Let us know if one or both ovaries were removed. Do you know if the fallopian tubes were removed?

Please list pathology information on each biopsy, if available.

		Select
		Normal
		Abnormal

please list parent if known.

(eg. Maternal cousin with colon cancer at 35: now age 40; his mother is Mary)

(eg. Mary-45, Alice-43, Jen-40)

(eg. Rob-42, Joe-40, Steve-39)

include any deceased siblings. For all others: list age at diagnosis and current age.

(eg. Brother Steve diagnosed with testicular cancer at 32, now 40)

(format: daughter Mary was diagnosed with uterine cancer at age 40, now age 45)

List individual, age at diagnosis and current age. (eg. father had colon cancer at 65, is now 80, son had skin cancer at 45, is now 46)

Her current age, and tell us if she had breast, ovarian or bilateral breast cancer and age diagnosed.

Tell us if you have same mother or father (ex: brother Joe, 39 has same mother)

List the name of their parent, age at diagnosis, and current age, so we can place them properly in the pedigree.

(eg. Steve's daughter had breast cancer at 23, is now 35)

(eg. Mike-70, Cecelia-68, Joan-65)

(eg. Mel-62, Joseph-59, Sheila-55)

List name, age of diagnosis and current age.

(eg. Sheila, endometrial cancer at 30, now 55)

Provide Age(s)

Provide any information on cancer type, age of diagnosis, or approximate age of death. (ex: my mother's mother had breast cancer in her 40's and died in her late 80's)

Provide any information on cancer type, age of diagnosis, or approximate age of death.

(eg. I smoked a pack of cigarettes a day from age 20 to 40 but quit ten years ago.)

Please also list any other relatives with breast or ovarian cancer that you have not already mentioned.

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Discussions with a genetic counselor as offered by Genetic Laboratories and Genetic Testing Companies serve to provide key information for the understanding of genetic testing, although pedigree intake and record review may be focused to the results of genetic testing. Although laboratory license and permit and genetic counselor certification and licensure where applicable, do not permit the practice of medicine, genetic counselors can provide explanation and direction to physicians and authorized medical professionals for the interpretation of the results of genetic testing. Genetic counselors, upon physician waiver and in collaboration with ordering clinicians, can provide counseling on genetic testing and the meaning of test results. Comprehensive genetic counseling may be available through physicians who can provide genetic counseling within the scope of their practices as they choose and through genetic counselors within the scope of their practice. Please note that patient management and genetic counseling surrounding on-going prenatal or any diagnostic testing is best handled by Physicians, Maternal/Fetal and Pediatric Genetics specialists, in conjunction with clinical services where they are available and in collaboration with genetic counselors and other genetic specialists.

Please complete this form in one session and submit

1. Today's Date (Month/Day/Year)

2. What is your reason for obtaining genetic information?

3. First Name, M.I.

4. Last Name

5. Date of Birth (Month/Day/Year)

6. Age

7. Weight (lbs. and oz.)

8. Height (ft. and in.)

9. Birth Gender, surgeries since?

10. Ethnicity (eg: Ashkenazi Jewish, French, American Indian, etc.)

11. Have you or any relatives had cancer genetic testing? Explain.

12. Age at onset of menstrual cycles (if applicable)

13. Your Age at birth of your first child

14. Please list all of your biological children and their ages

15. Have you entered menopause? At what age? (if applicable)

16. Have you ever had any cancer?

17. If yes, list cancer and age age at diagnosis

18. Have you ever been diagnosed with a precancerous condition?

19. If yes, how old were you and what type of precancerous condition?

20. Other Cancers/Medical Conditions

21. Year that your ovaries were removed (if applicable)

22. Have you had surgery to remove your uterus? (if applicable)

23. Have you ever had surgery to remove any other organs? when.

24. If yes, list organ(s) and date(s) removed

25. Have you ever had a breast biopsy?

26. How many biopsies have you had?

27. What were the results of your biopsy?

28. Ever use hormonal therapy, how long and how long ago?

29. If yes, what type?

30. If yes, please explain

31. Have you ever been exposed to excessive radiation or x-rays?

32. Please list relatives with early Cancer diagnosis

33. List all your sisters by first name and age

34. List all your brothers by first name and age

35. Do any of your brothers and/or sisters have cancer? If so, who?

36. Have any children been diagnosed with cancer?

37. Did any first degree relatives (your parents or children) have cancer?

38. Did your mother have breast, ovarian or bilat. breast ca./ also age

39. Have you had breast hyperplasia, atypia, breast disease

40. month/year of most recent colonoscopy

41. month/year of most recent mammogram

42. List any half brothers or sisters

43. Do any of your nieces or nephews have cancer?

44. List your mother's brothers and sisters and ages

45. List your father's brothers and sisters and ages

46. Do any of your aunts or uncles have cancer? Who?

47. List any maternal relatives who died at a young age

48. Did either of your maternal grandparents have cancer or die young?

49. Did either of your paternal grandparents have cancer or die young?

50. Please discuss your alcohol and smoking history.

51. Please list any additional information you feel may be useful to us

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