Vanderbilt Hereditary Cancer Clinic FAMILY HISTORY QUESTIONNAIRE The information in this questionnaire will be used to draw your family history diagram (also known as a pedigree) For unknown information, use approximates Examples: Diagnosed: mid-50’s 10 - 20 colon polyps When known, record specific cancer types and/or pathology General: Kidney cancer Specific: Clear cell renal cell carcinoma
Please include all family members asked about in this questionnaire, no matter if they have had cancer or not, or if they are living or deceased. o If you have many cousins, list only those who have had cancer
If there is not enough space, use the back of the page, or add additional sheets. Example: Name
Current Age or Age of Death
Cancers, tumors, or growths
Age at diagnosis
Father
John
65
colon polyps: 7 adenomatous 3 hyperplastic
55
Father’s Mother
Jane
49
Bilateral breast cancer, triple negative
45, 49
If you have questions about this form, please contact the Hereditary Cancer Clinic at: Phone: Fax: Mail:
(615) 322-2064 (615) 343-3343 Hereditary Cancer Clinic Village at Vanderbilt, Suite 2500, 1500 21st Ave South Nashville, TN 37212
Please have this form for reference during your telephone appointment.
YOURSELF Name: ___________________________________________________________________ Date of Birth: ____________________________________________ Cancers, tumors or growths:
Age at diagnosis:
_________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Your Children Name
Current Age or Age of Death
Cancers, tumors, or growths
Age at diagnosis
Your Brothers and Sisters Please note half siblings Name
Page | 2
Full or Half
Current Age or Age of Death
Cancers, tumors, or growths
Age at diagnosis
Your Father’s Relatives Ancestry/Ethnic background (German, African American, Jewish, etc.) __________________________
Name
Current Age or Age of Death
Cancers, tumors, or growths
Age at
diagnosis
Cause of death, if deceased
Father Father’s Father Father’s Mother
Your Paternal Aunts and Uncles (Father’s Brothers and Sisters) Name
Current Age or Age of Death
Cancers, tumors, or growths
Age at diagnosis
Your Paternal Cousins (list only cousins who have had cancer) Name
Page | 3
Their parent’s name
Current Age or Age of Death
Cancers, tumors, or growths
Age at diagnosis
Your Mother’s Relatives Ancestry/Ethnic background (German, African American, Jewish, etc.) __________________________ Name
Current Age or Age of Death
Cancers, tumors, or growths
Age at
diagnosis
Cause of death, if deceased
Mother Mother’s Father Mother’s Mother
Your Maternal Aunts and Uncles (Mother’s Brothers and Sisters) Name
Current Age or Age of Death
Cancers, tumors, or growths
Age at diagnosis
Your Maternal Cousins (list only cousins who have had cancer) Name
Page | 4
Their parent’s name
Current Age or Age of Death
Cancers, tumors, or growths
Age at diagnosis
Relatives in Your Extended Family with Cancer, Tumors or Growths Not listed on this Form (for example, great aunts or uncles) List any other relatives you know of that have had a cancer, tumor, or growth Name
Relationship to you (mother’s or father’s side?)
Example
Page | 5
Father’s mother’s sister (great aunt)
Current Age or Age at Death
80
Cancer(s)
Age at diagnosis
Melanoma
65