Please check for those that apply to YOU and/or YOUR FAMILY (on both your mother’s/maternal or father’s/paternal side). Next to each statement, please list the relationship to you and age of diagnosis.

You and the following family members should be considered: Mother Father Brother Sister Children Paternal Uncle/Aunt Maternal Uncle/Aunt First Cousins Niece/Nephew Maternal Grandmother/Grandfather Paternal Grandmother/Grandfather.

Each statement should be answered individually, so you may list the same cancer diagnosis more than once as you answer these questions. This is a screening tool for the common features of hereditary cancer syndromes. Share this information with your healthcare professional to help determine your hereditary cancer risk.