Tuesday, 4 December 2012



Sydney Cancer Genetics Family History Questionnaire

Thank you for taking the time to complete your family history. A glance into your past can provide clues to whether or not your family has a higher risk of cancer than the general population. We use the information you provide to personalise screening and other cancer risk reducing strategies for you and your family. It remains confidential.

Record all relatives, whether they have had cancer or not. Include for each person:

Full Name and Date of Birth (or approximate age if date of birth not known)

If they had cancer, how old were they when diagnosed and what type of cancer it was

For relatives who have died, record the age they were when they died and cause of death

Some documents that can be helpful regarding any cancer in your family are:

doctor’s letters describing the type of cancer and any treatment

pathology reports about the type of cancer

death certificates

the genetic test report, if genetic testing has been performed or contact details of the genetic testing service.

Start with yourself. Also record your family’s ethnicity (eg British, Ashkenazi Jewish, Chinese). Then record your first degree relatives (children, brothers and sisters, parents), followed by your second degree relatives (grandparents, aunts and uncles, nieces and nephews). Include any third degree relatives (cousins, great-aunts and great-uncles) if they have had cancer.

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Example of how to complete the Family History Questionnaire

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|Family history for: |

|Name, date of birth: |

|Ethnicity (eg Ashkenazi Jewish) |

|Any genetic testing? If so, who, where it was done and result |

|Relation |Name |Date of Birth |Cancer? Age, type |If deceased, age and cause |

|Self | | | | |

|Sister(s) | | | | |

|Brother(s) | | | | |

|Mother | | | | |

|Father | | | | |

|Mother's father | | | | |

|(maternal grandfather) | | | | |

|Mother's mother | | | | |

|(maternal grandmother) | | | | |

|Father's father |  | |  |  |

|(paternal grandfather) | | | | |

|Father's mother |  |  |  |  |

|(paternal grandmother) | | | | |

|Mother's sister(s) | | | | |

|(maternal aunts) | | | | |

|Mother's brother(s) | | | | |

|(maternal uncles) | | | | |

|Father's sisters(s) | | | | |

|(paternal aunts) | | | | |

|Father's brother(s) | | | | |

|(paternal uncles) | | | | |

|Your children | | | | |

|Your nieces and nephews. (your | | | | |

|brothers’ and sisters’ | | | | |

|children) | | | | |

|Other relatives with cancer: | | | | |

|(include full name and who | | | | |

|related to eg: Jane Doe, Uncle | | | | |

|John Doe’s daughter | | | | |

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