Risk Assessment – My Faulty Gene

Name

Have you or any of your first degree family members had heart disease before the age of 60?

Yes

Have you or any of your first degree family members had diabetes? “Diabetes” is also known as type 2 diabetes or non-insulin dependent diabetes. If YES, please specify relationship below.

Yes

Have you or any of your first degree family members had melanoma? If YES, please specify relationship below.

Yes

Have you or any of your first degree family members had colorectal cancer before the age of 55? If YES, please specify relationship below.

Yes

Do you have more than one relative on the same side of the family who has had colorectal cancer at any age? Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, cousins, nieces, nephews and grandchildren. If YES, please specify relationship below.

Yes

Have you or any of your first degree family members had prostate cancer before the age of 60? If YES, please specify relationship below.

Yes

Have you or any of your first degree family members had breast cancer before the age of 50? If YES, please specify relationship below.

Yes

Do you have more than one relative on the same side of your family who has had breast cancer at any age? Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, cousins, nieces, nephews and grandchildren. If YES, please specify relationship below.

Yes

How is your health in general?

Are there any other conditions or illnesses which run in your family? If so, please specify.

Have you or any of your close relatives ever had genetic testing? If so, please specify.

Please include any additional information you believe may be relevant to your family’s history of diseases or disorders in the space below: