Family History Form
Race (check all that apply)
Ashkenazi Jewish
Black/African-American
Middle Eastern
Pacific Islander
Asian
Hispanic/Latino
Native American
White/Non-Hispanic
Other:
Are you adopted?
(If you selected “Yes” and do not know your family history, please go to the last step)
Yes
No
Do you have a FAMILY HISTORY of PROSTATE CANCER?
Yes
No
If you selected “Yes”, please check all that apply:
Father
Brother
Grandfather
More than 1 relative
Other:
Were any of the above relatives diagnosed with prostate cancer before the age of 60?
Yes
No
Unknown
Do you have a FAMILY HISTORY of BREAST CANCER?
Yes
No
If you selected “Yes”, please check all that apply:
Mother
Sister
Grandmother
More than 1 relative
Other:
Is there history of MALE breast cancer?
Yes
No
If yes, please state which relative:
Were any of the above relatives diagnosed with breast cancer before the age of 60?
Yes
No
Unknown
Do you have a FAMILY HISTORY of OVARIAN CANCER?
Yes
No
If you selected “Yes”, please check all that apply:
Mother
Sister
Grandmother
More than 1 relative
Other:
Were any of the above relatives diagnosed with breast cancer before the age of 50?
Yes
No
Unknown
Do you have any family history of GASTRIC/COLON CANCER?
Yes
No
Unknown
If yes, please state which relative and age of diagnosis:
Do you have any family history of Lynch syndrome cancers
Colorectal, endometrial, gastric, ovarian, exocrine pancreas, upper tract urothelial, glioblastoma, biliary tract, and small intestinal cancer?
Yes
No
Unknown
If any below boxes are selected, patient is likely covered by insurance for testing
* Hereditary Breast and Ovarian Cancer
Ashkenazi Jewish
Adopted
Personal history of prostate cancer or male breast cancer
2 or more family members with prostate cancer or HBOC-related cancers*
At least one family member with pancreatic or ovarian cancer
Known family History of Lynch syndrome
Known familial Rare Pathogenic Mutation
Diagnosis of NCCN High, Very High or Metastatic Prostate Cancer
Diagnosis of Prostate Cancer with intraductal or cribriform pathology
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