Roswell Park Clinical Genetics Service Questionnaire

This questionnaire will only be viewed by the clinical genetics professionals and will be kept confidential. We will contact you within 1 week from the date on which you have sent the completed questionnaire to our office.

About You...

Last Name
First Name
Street Address
 Apt #
City/Town, State
 Zip Code
Telephone
 Best time to contact you?
Date of Birth
E-mail

Do you have a personal history of cancer? Yes No

If yes, please answer the following questions:

a. How many cancers have you had?
b. How many of these cancers were different types of cancer (not the spread of the original cancer)?
c. Please list type(s) of cancer you have had and your age when diagnosed:

Cancer Age at Diagnosis

Are you adopted? Yes No

If yes, please answer the following questions:

a. Do you know about your birth mother's health and family history? Yes No
b. Do you know about your birth father's health and family history? Yes No

If you do not know any information about your biological relatives, please skip the Family History section.  Otherwise, please complete the Family History section.

Family History...

List the countries / parts of the world your mother's family is from:

List the countries / parts of the world your father's family is from:

List the religious background of your mother's family:

List the religious background of your father's family:

We need to know which (if any) of your relatives have been diagnosed with cancer, the type(s) of cancer they had, and their age(s) at diagnosis. The relatives you list below should include only those related to you through blood, not through marriage.

Your relative Living? (y or n) Cancer? (y or n) Type(s) of cancer Age at diagnosis
Mother Yes No Yes No
Father Yes No Yes No
Mother's mother Yes No Yes No
Mother's father Yes No Yes No
Father's mother Yes No Yes No
Father's father Yes No Yes No

Your relative Total # Total # living


Total # with cancer

Living

Deceased
Children
Sisters
Half-sisters
Brothers
Half-brothers
Nieces
Nephews
Mother's sisters
Mother's brothers
Father's sisters
Father's brothers

If any relatives listed earlier have had cancer, please complete the following:

Relative
Example: sister		 Type(s) of cancer
breast		 Age(s) at Diagnosis
about 45y

Please provide the following information on any other blood relative who had had cancer:

Relative
Example: mother's cousin		 Type(s) of cancer
colon		 Age(s) at Diagnosis
about 53y

Are there any other medical or health conditions that two or more people in the family have (such as polyps, moles, diabetes, heart disease, etc.)?
Yes No

Do you have any relative with a genetic condition? Yes No

If yes, to either question, please complete the following:

Type of Condition
Example: moles		 Relatives with Condition
self, brother, father

Please forward the completed questionnaire to the Clinical Genetics Service by clicking on the "SEND" icon below.  Thank you for your inquiry.  We look forward to speaking with you.