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.

Possible Candidate for Genetic Testing Form

If this Is a Medical Emergency, please dial 911.‚Äč

* Three receptors (ER, PR, HER2) are negative on pathology report.

** Pathology report notes presence of tumor infiltrating lymphocytes, Chron's-like lymphocytic reaction, mucinous/signet-ring differentiation or medullary growth pattern..

*** Adenomatous (pre-cancerous) type polyps.