Patient Forms – Family Questionnaire

Family History Questionnaire

Completing this questionnaire will help us to determine the risk of a hereditary cancer predisposition in your family.

Please answer these questions as completely as possible. If you are uncertain about any information, please write in your best guess or write unknown.

Names of family members are used only as a reference. This information will not be used to contact your relatives.

If yourself or any family member is transgender or non-binary, please make a note on the last page so that we can assess organs at risk for cancer.

If you have questions, please contact our office at 714-288-3500. Submit the completed form by clicking the 'Submit to Genetics Center' button below. Alternatively, you may fax the completed questionnaire to 714-288-3510, or drop off your completed questionnaire to Genetics Center at least 2 days prior to your appointment.

PERSONAL HISTORY* After two hours of inactivity, form data will be removed. Name: * Last * Maiden Date of birth: *
Have you ever been diagnosed with cancer?
Yes No Unknown (U)
If yes, what type(s) and at what age(s) were you diagnosed? (below)

Age at Diagnosis	Cancer Location	Pathology (Cancer Type)	Treatment
Example: 45	Breast	Lobular Carcinoma	Chemotherapy, lumpectomy

SCREENING HISTORY - WOMEN ONLY Age at first period
Age at first live birth (if applicable)

Have you ever used oral contraceptives?
Yes    No    Unknown If yes, how many years?
Between what ages?

Have you gone through menopause yet?
Yes    No    Unknown If yes, at what age?

Have you taken hormone replacement therapy?
Yes    No    Unknown If yes, how many years?

Have you had any breast biopsies?
Yes    No    Unknown If yes, how many?
If yes, at what age(s)?

Was atypical hyperplasia seen?
Yes    No    Unknown If atypical hyperplasia?
DCIS    LCIS
Have you had a hysterectomy (removal of uterus)?
Yes    No    Unknown If yes, at what age?
Reason:

Have you had an oophorectomy (removal of ovaries)?
Yes    No    Unknown If yes, at what age?
If yes,
Right    Left    Bilateral
Reason:

SCREENING HISTORY - MEN AND WOMEN Have you had a colectomy (removal of colon)?
Yes    No    Unknown If yes, at what age?
If yes,
Partial    Complete    Unknown
Reason:

Have you ever had colon polyps?
Yes    No    Unknown If yes, how many?
If yes, what type?

Have you been diagnosed with ulcerative colitis?
Yes    No    Unknown If yes, at what age?

Have you had a mastectomy (removal of breast tissue)?
Yes    No    Unknown If yes, at what age(s)?
If yes,
Right    Left    Bilateral
Reason:

Have you been diagnosed with fibrocystic breast disease?
Yes    No    Unknown
Have you had a thyroidectomy (removal of thyroid)?
Yes    No    Unknown If yes, at what age?
Reason:

Have you had any other surgeries?
Yes    No    Unknown If yes, what?

Have you had unusual skin findings (lumps, bump, lesions, light or dark spots)?
Yes    No    Unknown If yes, what?

Have you or a family member ever been diagnosed with a genetic disorder?
Yes    No    Unknown If yes, what?
Who?

* If you are experiencing difficulties with this form, please contact (714) 288-3500 for assistance. Thank you.

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