1 | Do you think that there are any conditions or illnesses that run in your family? If so, please specify:________________ | □ | □ |
2 | Have any of your close relatives, including parent(s), children, brother(s), or sister(s), had heart disease (also known as cardiovascular disease, heart attack, angina, bypass surgery) before the age of 60? | □ | □ |
3 a | Have any of your close relatives, including parent(s), children, brother(s), or sister(s), had diabetes (also known as type 2 diabetes or non-insulin-dependent diabetes)? | □ | □ |
4 | Do you come from any of the following ancestry? People from these backgrounds may be at increased risk of diabetes | | |
(a) South East Asia | □ | □ |
(b) Indian subcontinent, that is, India, Pakistan, Bangladesh | □ | □ |
5 | Have any of your close male relatives, including father, son(s), or brother(s), had prostate cancer before the age of 60? | □ | □ |
6 a | Have any of your close female relatives, including mother, daughter(s), or sister(s), had ovarian cancer? | □ | □ |
7 | Have any of your close relatives, including parent(s), children, brother(s), or sister(s), had breast cancer before the age of 50? | □ | □ |
8 a | Do you have more than one relative who has had breast cancer on either your mother’s or father’s side of the family? Please think about all of the following relatives: parent(s), children, brother(s), sister(s), grandparent(s), aunt(s), uncle(s), niece(s), nephew(s), and grandchildren. | □ | □ |
9 | (a) Is your family of Jewish ancestry? | □ | □ |
(b) If so, are they from Eastern or Central Europe (Ashkenazi)? | □ | □ |
People from these backgrounds may be at increased risk of breast cancer | | |
10 a | Have any of your close relatives, including parents(s), children, brother(s), or sister(s), had colon or rectal cancer (also known as large bowel or colorectal cancer) before the age of 55? | □ | □ |
11 a | Do you have more than one relative who has had colon or rectal cancer on either your mother’s or father’s side of the family? | □ | □ |
Please think about all of the following relatives: parent(s), children, brother(s), sister(s), grandparent(s), aunt(s), uncle(s), niece(s), nephew(s), and grandchildren. | | |
12 | On either of your mother’s or father’s side of the family, thinking about the following relatives: parent(s), children, brother(s), sister(s), grandparent(s), aunt(s), uncle(s), niece(s), nephew(s), and grandchildren, do you have more than one relative who has had: | | |
(a) Any cancer? | □ | □ |
(b) Any of the following types of cancer: brain, kidney, thyroid, stomach, uterus/endometrial, pancreas? | □ | □ |