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:

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:

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:

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