Cancer family history questionnaire - St Charles Health System 2026

1. Click ‘Get Form’ to open the cancer family history questionnaire in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your first name, last name, age, sex, today's date, healthcare provider's name, and date of birth.
3. In the 'You and Your Family’s Cancer History' section, carefully review each cancer type listed. For each type, indicate whether there is a personal or family history by selecting 'Yes' or 'No'.
4. Next to each cancer type, provide details about your relationship to the affected family members and their age at diagnosis. Include all close blood relatives as specified.
5. Complete the 'Family History Review' section with your healthcare provider. Check all applicable concerns regarding personal or family history of cancer.
6. Finally, sign and date the form in the 'Signatures' section for both patient and provider.

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