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Cancer family history questionnaire - Pineview Gynecology

Cancer family history questionnaire - Pineview Gynecology 2025

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The document is a Cancer Family History Questionnaire designed for patients to complete prior to their appointment at Pineview Gynecology. It collects personal and family cancer history, requiring patients to indicate any cancers diagnosed in themselves or their blood relatives, along with ages of diagnosis. The form also includes questions about Ashkenazi Jewish descent and previous genetic testing for hereditary cancer syndromes. It aims to assess cancer risk and guide further testing or education.

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Click ‘Get Form’ to open the Cancer family history questionnaire in the editor.
Begin by filling out your personal information, including your name, date of birth, age, and appointment date. Ensure accuracy as this information is crucial for your medical records.
In the cancer history section, mark 'Y' for any cancers that apply to you or your family members. For each marked item, specify the relationship to you and the age at which they were diagnosed.
Be thorough when listing family members affected by cancer. Include all relevant blood relatives such as parents, siblings, and grandparents.
Answer additional questions regarding Ashkenazi Jewish descent and any concerns about personal or family cancer history. If applicable, provide details about genetic testing results.
Finally, sign and date the form at the bottom. This confirms that all information provided is accurate to the best of your knowledge.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a second degree family history of cancer?

Second degree relatives include aunts, uncles, grandparents, nieces, nephews and half siblings. You may also be referred if there is cancer in your family and: You have Jewish ancestry. You or a relative has had sarcoma (cancer in the docHub tissues, for example in the muscle or bone) before the age of 45.

What is considered a strong family history of ovarian cancer?

Women with a grandmother, mother, daughter or sister with ovarian cancer but no known genetic mutation still have an increased risk of developing ovarian cancer. The lifetime risk of a woman who has a first degree relative with ovarian cancer is five percent (the average womans lifetime risk is 1.4 percent).

Is cancer hereditary from mother or father?

Is cancer hereditary? Cancer itself cant be passed down from parents to children. And genetic changes in tumor cells cant be passed down. But a genetic change that increases the risk of cancer can be passed down (inherited) if it is present in a parents egg or cells.