(First name only (ex: breast, Now or diagnosis okay) Examples: thyroid, colon, etc) Age at (Estimate) Aunt – Mom’s side, Death M (male) or Great aunt –Dad’s father’s sister, For breast, indicate (N or D) F (female) Cousin - Aunt Jennie’s daughter if cancer is in both (ex: 55 N) breasts (bilateral) Has anyone in your family tested positive for a mutation in a cancer gene? Yes No if yes, what gene?______________________________________________________________ (if yes, please bring a copy of your family member’s test result to your appointment) Your Family Tree Mother Age: Father Age: (now or age deceased) (now or age deceased)
(First name only okay) M (male) or F (female) Examples: Aunt – Mom’s side, Great aunt –Dad’s father’s sister, Cousin - Aunt Jennie’s daughter Now or Age at Death (N or D) (ex: 55 N) (ex: breast, thyroid, colon, etc) For breast, indicate if cancer is in both breasts (bilateral) diagnosis (Estimate) Has anyone in your family tested positive for a mutation in a cancer gene? Yes No if yes, what gene?______________________________________________________________ (if yes, please bring a copy of your family member’s test result to your appointment) Your Family Tree Mother Age: (now or age deceased) Father Age: (now or age deceased)
HCRPQuestionnaire%20IRB%20Approved%202012.docx