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