Personal and Cancer History - Updated June 2021

Personal and Cancer History
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
DOB*

MonthDayYear
Date
Age
If you have the following insurance, call for information on coverage before moving forward with cancer genetic testing:
Medicare with no secondary insurance
Complete the section below. Include yourself and all 1st and 2nd degree male and female blood relatives on both your mother’s and father’s sides. Specify which relatives were affected and estimate ages of diagnosis to the best of your ability.

1st Degree Relatives: Parents, Siblings, Children
2nd Degree Relatives: Grandparents, Aunts/Uncles, Nieces/Nephews
Breast Cancer

YouSiblings/childrenMother's sideFather's side
Please list relative(s) and age of diagnosis, e.g. "Sister, 42"
Ovarian Cancer

YouSiblings/childrenMother's sideFather's side
Please list relative(s) and age of diagnosis, e.g. "Sister, 42"
Ashkenazi Jewish heritage with BREAST CANCER at any age

YouSiblings/childrenMother's sideFather's side
Please list relative(s) and age of diagnosis, e.g. "Sister, 42"
3 or more BREAST, PROSTATE,and/or PANCREATIC CANCERS on one family side, any ages

YouSiblings/childrenMother's sideFather's side
Please list relative(s) and age of diagnosis, e.g. "Sister, 42"
MALE BREAST CANCER

YouSiblings/childrenMother's sideFather's side
Please list relative(s) and age of diagnosis, e.g. "Father, 42"
2 or more COLON CANCERS on a family side, at least one under 50

YouSiblings/childrenMother's sideFather's side
Please list relative(s) and age of diagnosis, e.g. "Father, 72 and Brother, 48"
3 or more COLON or UTERINECANCERS on a family side, any ages

YouSiblings/childrenMother's sideFather's side
Please list relative(s) and age of diagnosis, e.g. "Father, 72 and Brother, 48"
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