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Family history questionnaire
for genetic counselling

Section One
Background

Tell us a bit about yourself

Title

First name

Last name

Maiden name

Date of birth

Occupation

Address

Suburb

State

Postcode

Email

Home phone (optional)

Work phone (optional)

Mobile phone

Your GP's details

GP's First name

GP's Last name

Phone

Address

Suburb

State

Postcode

Genetic counselling

Has anyone in your family ever had genetic counselling?

 

Relatives who have had genetic counselling

Relative 1 - Details

First Name

Last Name

Relationship to you

Date of birth

Unsure of Date of birth

Deceased?

Date of Death

Unsure of Date of death

Where were they seen?

Did they have genetic testing?

Outcome of genetic testing

Section Two
Personal history

Cancer

Have you ever had cancer?

 

Personal history of cancer

Cancer Diagnosis 1

Date of Diagnosis

Specialist

Where were you seen?

Pathology Report (Multiple files allowed)

Cancer surveillance

Have you ever had cancer surveillance?
(e.g. mammogram, colonoscopy, gastroscopy)?

 

Personal history of cancer surveillance

Procedure 1

Date of Procedure

Specialist

Outcome of procedure

Pathology Report (If you have access to copies)

Section Three
Family history

Your mother

Mother's First Name

Mother's Last Name

Date of Birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your father

Father's First Name

Father's Last Name

Date of Birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your maternal grandmother

Maternal Grandmother's First Name

Maternal Grandmother's Last Name

Date of Birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your maternal grandfather

Maternal Grandfather's First Name

Maternal Grandfather's Last Name

Date of Birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your paternal grandmother

Paternal Grandmother's First Name

Paternal Grandmother's Last Name

Date of Birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your paternal grandfather

Paternal Grandfather's First Name

Paternal Grandfather's Last Name

Date of birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Complete if applicable

Your children
(with or without cancer)

Child 1's Details


First Name

Last Name

Gender

Date of birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your brothers and sisters
(with or without cancer)

Child 1's Details


Sibling's First Name

Last Name

Half Sibling?

Gender

Date of birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your nieces & nephew
(with or without cancer)

Niece/Nephew 1's Details


Niece/Nephew's First Name

Last Name

Gender

Name of the Sibling who is the parent

Date of birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your mother's brothers & sisters
(with or without cancer)

Aunt/Uncle 1's Details


Aunt/Uncle's First Name

Last Name

Gender

Date of birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Your father's brothers & sisters
(with or without cancer)

Aunt/Uncle 1's Details


Aunt/Uncle's First Name

Last Name

Gender

Date of birth

Unsure of DOB

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Any other blood relative with cancer

Blood Relative 1's Details

Blood Relative's First Name

Blood Relative's Last Name

Relationship

Type of Relative

Date of birth

Unsure of DOB

Gender

Deceased?

Date of Death

Unsure of DOD

Type(s) of cancer
(i.e. where cancer started)

Type of Cancer 1

Age at Diagnosis

Other History (number of colon polyps, uterine fibroids, other benign tumors, thyroid disease, etc.)

Pathology Report (If you have access to copies)

Section Four
Additional information

Additional information

Are there any significant health conditions other than cancer that have affected your family?

Is there any other information that could facilitate your genetic counselling?

Thank you

  • Please note that the information supplied is confidential and patient privacy is always maintained.
  • I declare that all information written on the above form is true to the best of my knowledge.
  • Medical students may be present during examinations, if you do not wish this, please inform your genetic counsellor.
  • I consent for my medical information to be forwarded to other health professionals if necessary.