FAMILY HISTORY QUESTIONAIRE FOR RISK OF HEREDITARY COLON CANCER

 
   Are You at Risk for Cancer?

Genetic testing and advances in knowledge have demonstrated a family tendency to develop COLORECTAL CANCER. Are you in that category? Is your risk higher? The form provided will help us determine if you need further assessment.

Please check the boxes below for yourself and for each family member who has had cancer as indicated.

Subject Colon Cancer Colon Polyps # Endometrial Cancer Other Cancers at any age Before Age 50 After Age 50 Before Age 50 After Age 50 Yourself Mother Father Sisters Brothers Daughters Sons Mother’s Side Grandfather Grandmother Aunts Uncles Cousins Father’s Side Grandfather Grandmother Aunts Uncles Cousins Have your physician evaluate your risk for hereditary colon cancer if you have a personal/family history of: Colorectal cancer diagnosed before age 50 Endometrial cancer in combination with colorectal cancer Two or more cancers in the same individual (two colon cancers) More than 20 cumulative colorectal polyps over multiple exams May we contact you for more information, if necessary? Contact Me Yes No Name Phone Email Address City, State, Zip Comments