Download Family Cancer History Form

Family Cancer History Form
Information about your personal and family history of cancer is important to ensure that we are able to provide you with the
most appropriate medical management recommendations. Please take some time to complete the following questionnaire and
bring the completed form to your appointment for review with your provider.
Your History
1. Have you been diagnosed with colon or rectal cancer?
No
Yes (one time)
Yes (2 or more separate colon cancers)
How old were you when you were diagnosed with colon or rectal cancer?
2. Have you been diagnosed with endometrial (uterine) cancer?
No
Yes
How old were you when you were diagnosed with endometrial (uterine) cancer?
3. Have you been diagnosed with any of the following cancers (circle):
Ovarian, stomach, small intestine, urinary tract/kidney, bile duct, brain, pancreatic or sebaceous tumors
Family History:
These questions apply to your first degree relatives (mother, father, brother, sister, children)
1. How many first degree relatives have been diagnosed with colon or rectal cancer?
None
One
Two or more first degree relatives
At what ages were they diagnosed with colon or rectal cancer?
2. How many first degree relatives have been diagnosed with endometrial (uterine) cancer?
None
One
Two or more first degree relatives
At what ages were they diagnosed with endometrial (uterine) cancer?
3. Have any of your first degree relatives been diagnosed with any of the following cancers (circle):
Ovarian, stomach, small intestine, urinary tract/kidney, bile duct, brain, pancreatic or sebaceous tumors
These questions apply to your second degree relatives (aunt, uncle, grandmother, grandfather, niece, nephew)
1. How many second degree relatives have been diagnosed with colon or rectal cancer?
None
One
Two or more second degree relatives
At what ages were they diagnosed with colon or rectal cancer?
2. How many second degree relatives have been diagnosed with endometrial (uterine) cancer?
None
One
Two or more second degree relatives
At what ages were they diagnosed with endometrial (uterine) cancer?
3. Have any of your second degree relatives been diagnosed with any of the following cancers (circle):
Ovarian, stomach, small intestine, urinary tract/kidney, bile duct, brain, pancreatic or sebaceous tumors