BRIEF FAMILY HISTORY QUESTIONAIRE

Check each box that applies to you:

“close family member” includes: parents, sisters/brothers, children, aunts/uncles, grandparents, cousins, and nieces/nephews.

NOTE: This BRIEF questionnaire will help you learn if the cancers in you/your family may be hereditary. If you decide to schedule an appointment with a genetic counselor you will need to provide more specific information to ensure an accurate assessment of your personal and family history.

	You, or any close family member*, has had a cancer diagnosed at an early age including: a. Breast cancer diagnosed before age 50 b. Colorectal (colon or rectal) cancer diagnosed before age 50 c. Endometrial (uterine) cancer diagnosed before age 50
	You, or any close family member, has been diagnosed with more than one cancer. Examples include: a. Breast and ovarian cancer b. Colorectal (colon or rectal) and endometrial (uterine) cancer c. More than one diagnosis of the same cancer (such as, two different breast cancers, or two different colon cancers). This does not include one cancer that spreads to another organ or another part of the body
	You, or any close family member, has been diagnosed with a rare cancer or rare pre-cancerous finding, such as: a. Male breast cancer b. Ovarian cancer c. More than five precancerous colorectal polyps (adenomas) d. Medullary thyroid cancer e. Adrenocortical carcinoma f. Phaeochromocytoma g. Paraganglioma h. Wilms’ tumor i. Retinoblastoma
	Two or more people in your family have been diagnosed with the same type of cancer (such as, 2 or more family members diagnosed with colon cancer) or related cancers, this might be: a. Breast and ovarian cancer b. Colorectal and endometrial (uterine) cancer
	You have any Ashkenazi (Eastern European) Jewish ancestry in your family. If so, you or a family member has had a diagnosis of breast, ovarian, or pancreatic cancer at any age.
	A health care provider has talked with you or a close family member about hereditary cancer.

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