FAMILY HISTORY FORM
G Number: _________________
Please complete and return to Genomic Medicine. Thank you.
YOUR DETAILS:
Surname: _______________________________________________ Any Jewish or Eastern European ancestry? Yes / No If yes: Mother’s side / Father’s side
First Name: ____________________________________________ (We ask this question because some genes are more common in some ethnic groups)
Date of Birth: __________________________________________
Home Tel. No: __________________________________________ Have any family members been seen by a genetics clinic? Yes / No
Mobile Tel. No: ________________________________________ Their name: _________________________________________________
Genetics Centre: __________________________________________
Please give as much information as possible about your relatives, including those who have not had cancer.
Relative |Full Name
including previous names |Date of Birth
Or age if unknown |Alive
Y / N |Date of Death
Or approx. year |If applicable | | | | | | |Type of Cancer
Or bowel polyps |Age at Diagnosis |Hospitals where Treated |Address when treated
(or town/ city if unknown) | |You |
| | | | | | | | |Your
Children |
| | | | | | | | | |
| | | | | | | | |Your
Sisters
(full or half) |
| | | | | | | | | |
| | | | | | | | | |
| | | | | | | | |Your Brothers
(full or half) |
| | | | | | | | | |
| | | | | | | | | |
| | | | | | | | |Relative |Full Name
including previous names |Date of Birth
Or age |Alive
Y / N |Date of Death
Or approx. year |If applicable | | | | | | |Type of Cancer
Or bowel polyps |Age at Diagnosis |Hospitals where Treated
(or town/ city if unknown)
|Address when treated
(or town/ city if unknown) | |Your
Mother | | | | | | | | | |Your
Father |
| | | | | | | | |Your Mother’s Mother | | | | | | | | | |Your Mother’s Father | | | | | | | | | |Your Father’s Mother | | | | | | | | | |Your Father’s Father |
| | | | | |
| | |Your Mother’s Brothers & Sisters |
| | | | | | | | | |
| | | | | | | | | | | | | | | | | | |Your Father’s Brothers & Sisters | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | |
Extra space for any other comments, extra relatives or anything else we need to know.
Use an additional sheet if required.
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Genomic Medicine
6th Floor, St Mary’s Hospital
Oxford Road, Manchester
M13 9WL
Tel: 0161 276 5430
Fax: 0161 276 6145
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Version 3 Created 17/01/18
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