Why have I been given a family history form?
You have been given a Family History Form because of concerns about the cancers that have
occurred in your family. This may be because there have been several cancers in your family or
because you or a relative had cancer at a young age. In most families, cancers will have
occurred by chance. However, a small proportion of cancers (less than 10%) are due to an
inherited predisposition. Before we try and answer your questions about your risk of cancers
and whether extra screening is beneficial for you, it is important to try and collect as much
information as possible about your family history, using this form.
How is the information I give used?
The information you provide will be used to:
✪ Assess your personal risk of developing cancer.
✪ Suggest an appropriate screening (surveillance) program for you.
✪ Help provide similar advice for other members of your family.
How should I fill in the form?
Please complete the form giving as much information as possible about your blood relatives,
including those who have not had cancer. Indicate half brothers and sisters with an asterisk (*)
and whether they are related to you through your mother or through your father. An example of
how to fill in a row for someone who has had cancer is given on the form. If you need extra
space, use the Additional Relatives sheet on the back of the Medical History Form, and you can
continue on a separate sheet if necessary.
What if I don’t know all these details?
If you do not know all the information, perhaps someone else in the family would be able to
help you. If this is not possible please do not worry, just provide the information you can. You
can write “don’t know” in the boxes you cannot fill.
Dates of birth/death: If you do not know the full date, the year or a rough date is still helpful
(eg. 1920-1930).
Type of cancer: We need to know where in the body individuals had cancer(s) (eg. breast,
bowel, lung) or if they have had bowel polyps. If a relative had cancer but you don’t know
where, write “Unknown cancer”. If a cancer started in one place and then spread to another, it
does NOT become a different cancer. For example, if breast cancer spread to someone’s bones,
it is only breast cancer. It is NOT now bone cancer.
Age at diagnosis: Please put the age at which your relative was diagnosed for each cancer they
had.
If you have any questions regarding this form please contact Caring For Women:
Phone (940) 591-6700
Email: forms@cfwdenton.com
Fax (940) 320-1220
Personal History
Name:
Date of Birth:
Which provider is your Cancer Prevention Plan schedule with?
Yes
Have you or any of your relatives had genetic testing?
If yes, please complete the information below.
Name
Relationship
Gene tested
No
Laboratory used
Result
Please check the ethnic/ racial background that best describes you and your parents. Check all that
apply.
White/ Caucasian
Black/ African American
Asian
Spanish/ Hispanic/ Latino
Unknown
Other
What countries are your ancestors from? (Example: Mexico, China, England)
Mother’s side:
Father’s side:
Is either side of your family of Ashkenazi (Eastern/Central European) Jewish descent?
Have you ever been diagnosed with any type of cancer?
If yes, what type(s) and at what age(s) were you diagnosed?
Age
Yes
Yes
No
Cancer Type
Age at first period
Age at first birth
Have you had any breast biopsies?
If yes, how many?
Yes
Age at menopause
No
If yes, at what age(s)?
If yes, what were the results?
Did the biopsy show atypical hyperplasia?
DCIS or LCIS?
Yes
No
Yes
No
Unknown
3
Have you had a hysterectomy (removal of uterus)?
If yes, at what age?
No
Reason
Have you had an oophorectomy (removal of ovaries)?
If yes, at what age?
Yes
Yes
No
Reason
Do you have unusual skin findings (lumps, bumps, lesions, light or dark spots)?
Describe:
Have you had colon polyps?
Yes
No
Type (example: hyperplastic, adenoma, etc.)
Age
Number
Yes
No
No
Family History
Your Biological Parents
First Name
Mother:
Father:
Alive/
Deceased
Current
age or
age at
death
Affected
with
cancer?
Age at
cancer
diagnosis
Type of
cancer
Smoker
A/D
Y/N
Y/N
A/D
Y/N
Y/N
Your Biological Grandparents
Current
age or
age at
death
Affected
with
cancer?
Age at
cancer
diagnosis
First Name
Alive/
Deceased
Type of
cancer
Your Mother’s Mother
A/D
Y/N
Y/N
Your Mother’s Father
A/D
Y/N
Y/N
Your Father’s Mother
A/D
Y/N
Y / NY / N
Your Father’s Father
A/D
Y/N
Y/N
Smoker
Your Biological Children
First Name
Alive/
Deceased
Current
age or
age at
death
Affected
with
cancer?
Age at
cancer
diagnosis
Smoker
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
Have any of the relatives listed on this page been diagnosed with colon polyps?
If so, please list names
Type of
cancer
Yes
No
Your Biological Brothers & Sisters
**Note – include full and half siblings. Please indicate any half siblings with an asterisk (*) and “M” or
“F” to indicate which parent you share.
Current
age or
Affected
Age at
Alive/
age at
with
cancer
First Name
Deceased
death
cancer? diagnosis
Cancer type
Smoker
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
Your Nieces & Nephews (Children of your brothers & sisters)
First Name
Sex
Child of
which
Alive/
sibling Deceased
Current
age or
age at
death
Affected
with
cancer?
Age at
cancer
diagnosis
Type of
cancer
Smoker
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
Have any of the relatives listed on this page been diagnosed with colon polyps?:
If so, please list names
Yes
No
Your Maternal Aunts & Uncles (your mother’s brothers and sisters)
First Name
Alive/
Deceased
Current age Affected
Age at
or age at
with
cancer
death
cancer? diagnosis
Type of
cancer
Smoker
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
Your Maternal Cousins (children of your maternal aunts & uncles)
First
Name
Sex
Child of
which
sibling
Current
age or
Alive/
age at
Deceased
death
Affected
Age at
with
cancer Type of
cancer? diagnosis cancer
Smoker
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
Have any of the relatives listed on this page been diagnosed with colon polyps?
If so, please list names
Yes
No
Your Paternal Aunts & Uncles (your father’s brothers and sisters)
First
Name
Alive/
Deceased
Current age
or age at
death
Affected
with
cancer?
Age at
cancer
diagnosis
Type of
cancer
Smoker
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
A/D
Y/N
Y/N
Your Paternal Cousins (children of your paternal aunts and uncles)
First
Name
Sex
Child of
which
sibling
Alive/
Deceased
Current
age or
age at
death
Affected
with
cancer?
Age at
cancer
diagnosis
Type of
cancer
Smoker
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
M/F
A/D
Y/N
Y/N
Have any of the relatives listed on this page been diagnosed with colon polyps?
If so, please list names
Yes
No
Additional Relatives
Please list any additional relatives who have had cancer in the space below. Also note how this person is
related to you.
First
Name
Alive/
Deceased
Current
age or age
at death
Affected
with
cancer?
A/D
Y/N
A/D
Y/N
A/D
Y/N
A/D
Y/N
A/D
Y/N
A/D
Y/N
A/D
Y/N
A/D
Y/N
Please list any other important information here:
Age at
cancer
diagnosis
Type of
cancer
Related
How?