Hereditary Cancer Screening
Have you had genetic testing for cancer within the past 5 years?
Yes
No
Do you have an active cancer diagnosis?
Yes
No
Have you or a family member ever had cancer?
Yes
No
I have not had cancer, but I'm not sure about my family members.
Only certain types of cancer are associated with the need for genetic testing. What type of cancer(s) did you and/or your family members have?
Ovarian cancer (females only)
Pancreatic cancer
Uterine/Endometrial cancer (females only)
Prostate cancer that spread to other parts of the body (males only)
Breast cancer - MALE
Breast cancer - FEMALE
Colon/colorectal cancer
More than one type of cancer listed here occurred on the same side of the family
A type of cancer not listed here
I don't know OR I am not sure which to choose. (Note: If you choose the "I don't know" option, please be sure no other boxes are checked for this question.)
Please choose the item(s) that most accurately describe the breast cancer.
It was diagnosed at age 45 or younger.
The same person had breast cancer more than once.
More than 2 people on the same side of the family had breast cancer.
I had the breast cancer and I am of Ashkenazi Jewish ancestry.
None of these apply (Note: If you choose "None of these apply", please be sure no other boxes are checked for this question.)
I don't know OR I am not sure which to choose (Note: If you choose "I don't know", please be sure no other boxes are checked for this question.)
Please choose the item(s) that most accurately describe the colorectal cancer.
It was diagnosed at age 50 or younger.
In addition to the person with colon cancer, at least 2 other people on the same side of the family also had cancer (of any kind).
None of these apply. (Note: If you choose "None of these apply", please be sure no other boxes are checked for this question.)
I don't know OR I am not sure which to choose. (Note: If you choose "I don't know", please be sure no other boxes are checked for this question.)
Please choose the item(s) that most accurately describe the uterine/endometrial cancer.
It was diagnosed at age 50 or younger.
In addition to the person with uterine cancer, at least 2 other people on the same side of the family also had cancer (of any kind).
None of these apply. (Note: If you choose "None of these apply", please be sure no other boxes are checked for this question.)
I don't know OR I am not sure which to choose. (Note: If you choose "I don't know", please be sure no other boxes are checked for this question.)
Please choose the item(s) that most accurately describe the breast and colon cancers.
Colorectal cancer was diagnosed at age 50 or younger.
Breast cancer was diagnosed at age 45 or younger.
More than 2 people on the same side of the family had breast cancer.
I had breast cancer and I am of Ashkenazi Jewish ancestry.
In addition to the person with colon or breast cancer, at least 2 other people on the same side of the family also had cancer (of any kind).
None of these apply. (Note: If you choose "None of these apply", please be sure no other boxes are checked for this question.)
I don't know OR I am not sure which to choose. (Note: If you choose "I don't know", please be sure no other boxes are checked for this question.)
Please choose the item(s) that most accurately describe the breast and uterine cancers.
Uterine cancer was diagnosed at age 50 or younger.
Breast cancer was diagnosed at age 45 or younger.
The same person had breast cancer more than once.
More than 2 people on the same side of the family had breast cancer.
I had breast cancer and I am of Ashkenazi Jewish ancestry.
In addition to the person with breast or uterine cancer, at least 2 other people on the same side of the family also had cancer (of any kind).
None of these apply. (Note: If you choose "None of these apply", please be sure no other boxes are checked for this question.)
I don't know OR I am not sure which to choose. (Note: If you choose "I don't know", please be sure no other boxes are checked for this question.)
Please choose the item(s) that most accurately describe the breast, colon, and uterine cancers.
Colorectal or uterine cancer was diagnosed at age 50 or younger.
Breast cancer was diagnosed at age 45 or younger.
The same person had breast cancer more than once.
More than 2 people on the same side of the family had breast cancer.
I had breast cancer and I am of Ashkenazi Jewish ancestry.
In addition to the person with breast, colon, and/or uterine cancer, at least 2 other people on the same side of the family also had cancer (of any kind).
None of these apply. (Note: If you choose "None of these apply", please be sure no other boxes are checked for this question.)
I don't know OR I am not sure which to choose. (Note: If you choose "I don't know", please be sure no other boxes are checked for this question.)
Please choose the item(s) that most accurately describe the colon and uterine cancers.
Colorectal or uterine cancer was diagnosed at age 50 or younger.
In addition to the person with colon or uterine cancer, at least 2 other people on the same side of the family also had cancer (of any kind).
None of these apply. (Note: If you choose "None of these apply", please be sure no other boxes are checked for this question.)
I don't know OR I am not sure which to choose. (Note: If you choose "I don't know", please be sure no other boxes are checked for this question.)
Based on your response, genetic testing may be of benefit to you. Would you like to speak to someone regarding genetic testing?
Yes.
No.
Based on your response, genetic testing is unlikely to be of benefit to you. Would you like to speak to someone regarding genetic testing?
Yes.
No.
Based on your response, it might be helpful to speak with someone to determine whether genetic testing is right for you. Would you like to speak to someone regarding genetic testing?
Yes.
No.
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