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Hereditary Breast & Ovarian Cancer Program

Family History Collection


FAMILY HISTORY COLLECTION TIPS
Use the attached forms to capture family cancer history. First determine who is in the family. Include at least parents, children, siblings, grandparents, aunts/uncles and first cousins. Expand to more distant relatives when it will help clarify patterns, or when there is an exceptional cancer history, such as very early age of onset or rare cancers. Once you have determined family structure, ask about cancer history. When time permits, consider including other notable family history, such as birth defects, distinctive physical features, and intellectual disability or autism. Family structure: Verify relationships, including half and step siblings, adopted individuals, and assisted reproduction with donor gamete. Ask about both paternal and maternal sides of the family Include unaffected and deceased relatives which can modify risk calculations by a genetics professional Dont forget to ask about ancestry When possible, clarify the location and type of cancer Ask about the presence of bilateral disease or multiple primary tumors Indicate approximate ages of diagnosis and death Indicate whether significant environmental risk factors are present. Dont forget to ask about cancers other than breast and ovarian Assess the familys level of certainty about the diagnosis (ie. are they sure it was ovarian cancer and not cervical or another female cancer?)

Disease expression:

FAMILY HISTORY RESOURCES


Collection Tools NCHPEG Family History Form: http://www.nchpeg.org/index.php?option=com_content&view=article&id=61&Itemid=74 Surgeon General's Family Health History: http://www.hhs.gov/familyhistory/ American Medical Association Genetics Family History Form: http://www.amaassn.org/resources/doc/genetics/adult_history.pdf Pedigree Drawing Software KUMC Clearinghouse of Pedigree Drawing Software: http://www.kumc.edu/gec/prof/genecomp.html#pedigree Tips and guidance for family history collection and pedigree drawing NCHPEG Family History Educational Aids: http://www.nchpeg.org/index.php?option=com_content&view=article&id=145&Itemid=64 American Medical Association: http://www.ama-assn.org/resources/doc/genetics/family_history02.pdf

Published September 2013 NCHPEG All rights reserved

FAMILY HISTORY QUESTIONNAIRE


Documented By: Maternal Family (Biological) Ethnic Background:
If Living Current Age If in Good Health Relationship Grandmother Grandfather Aunt(s) Uncle(s) 1) Cause of death 2) Age at death 3) Health problems

Date:

Historian: Paternal Family (Biological) Ethnic Background:


If Living Current Age If in Good Health Relationship Grandmother Grandfather Aunt(s) Uncle(s) 1) Cause of death 2) Age at death 3) Health Problems

Biological Mother
If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

Biological Father
If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

Sisters
If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

Brothers
If Living If in Good Health Name and current age if living 1)Cause of death 2) Age at death 3) Health problems

Daughters
If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

Sons
If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

Indicate whether adopted, half-siblings, and mono- or di-zygotic twins.

Published September 2013 NCHPEG All rights reserved

Other Maternal Relatives of Concern


If Living Current Age If in Good Health Relationship 1) Cause of death 2) Age at death 3) Health problems

Other Paternal Relatives of Concern


If Living Current Age If in Good Health Relationship 1) Cause of death 2) Age at death 3) Health Problems

Published September 2013 NCHPEG All rights reserved

Published September 2013 NCHPEG All rights reserved