OXFORD FAMILY CANCER CENTRE
Website: Clinical Genetics
DEPARTMENT OF CLINICAL GENETICS Churchill Hospital Old Road Headington Oxford OX3 7LE
Tel: 01865 226029 Fax: 01865 226011
As part of your referral to the Oxford Family Cancer Centre because of a history of cancer in your family, we need some information about your family to help us assess your risk of cancer. When completing the questionnai e! t is important to include those family members who ha!e not had cancer as well as family members who ha!e had cancer, as this will ha!e a bearin" on your o!erall cancer risk. Complete all sections to the best of your knowled"e. f a section is not applicable, please say so. f exact dates of birth and death and where the person was treated are not known then please put approximate dates and a"es and where in the country the person li!ed. #lease include people$s mai"en names or p e#ious names if you know them. %ore detailed instructions for completin" the &uestionnaire are a!ailable on our website or alternati!ely you may telephone our cancer tria"e nurses on '()*+ ,,+-,.. Your Name (full) Maiden/previous names Address Telephone Number (Day) (Evening) Date of birth Some types of genetic cancer are slightly more common in e!ish families" Are you or any of your ancestors e!ish# $es No %f yes& !hich side of your family has e!ish ancestry# 'ave you or a member of your family been seen by someone from any (enetics Department before no!# $es No %f Yes& !hich department# %f you have a )family number* Name of family member seen or )reference number* from that +here !as the clinic# (enetics Department& please Doctor/,ounsellor*s name !rite it here Appro-" Date 'ave you suffered from any ma.or illnesses& particularly any form of cancer& breast lump or bo!el polyp# /lease give details including dates& hospital and names of specialists seen" (0se a separate sheet of paper if you !ish") +ith your family history& !hat do you thin1 your ris1 of developing cancer is compared !ith someone in the general population# Much less Slightly less Same as Slightly higher Much higher +hat do you thin1 your chances are li1ely to be of developing cancer in your lifetime# (/lease mar1 on the line !ith an arro!) 2 32 422 No chance ,ertain to get it +hat are the main 5uestions or issues you !ould li1e to discuss !ith the cancer geneticist or genetic counsellor# (0se a separate sheet of paper if you !ish")
DEPARTMENT OF CLINICAL GENETICS, ,hurchill 'ospital, 6ld 7oad& 'eadington& 6-ford& 689 :;E& cancerA5uestionnaire (v?"9 Mar ?24? )
Tel< 24=>3 ??>2?@ /age 4 of :
DEPARTMENT OF CLINICAL GENETICS, ,hurchill 'ospital, 6ld 7oad& 'eadington& 6-ford& 689 :;E& cancerA5uestionnaire (v?"9 Mar ?24? )
Tel< 24=>3 ??>2?@ /age ? of :
You pa ents an" chil" en
$our Mother (full name) Maiden name Date of birth Alive Deceased %f not alive& date of death ;ast 1no!n Address 'er age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n) %f your mother had cancer B +here !as the cancer (eg left breast)
$our Father (full name) Date of birth Alive Deceased %f not alive& date of death ;ast 1no!n Address
%f your father had cancer B +here !as the cancer (eg prostate) 'is age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our Child (full name) Date of birth Male Demale Alive Deceased %f not alive& date of death ;ast 1no!n Address
,hild*s other are!t*s name %f your child had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our Child (full name) Date of birth Male Demale Alive Deceased %f not alive& date of death ;ast 1no!n Address
,hild*s other are!t*s name %f your child had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
/ f you ha!e more than , children, please put their details on the back of this sheet0
DEPARTMENT OF CLINICAL GENETICS, ,hurchill 'ospital, 6ld 7oad& 'eadington& 6-ford& 689 :;E& cancerA5uestionnaire (v?"9 Mar ?24? )
Tel< 24=>3 ??>2?@ /age 9 of :
You $ othe s an" siste s% &ull o hal& /if half, please tick whether you are related throu"h your mother or father0
$our "rother or Sister (full name) Date of birth Male Demale Alive Deceased %f not alive& date of death Dull brother/sister 'alf brother/sister %f half& through< mother father ;ast 1no!n Address< %f your brother/sister had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our "rother or Sister (full name) Date of birth Male Demale Alive Deceased %f not alive& date of death Dull brother/sister 'alf brother/sister %f half& through< mother father ;ast 1no!n Address<
%f your brother/sister had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our "rother or Sister (full name) Date of birth Male Demale Alive Deceased %f not alive& date of death Dull brother/sister 'alf brother/sister %f half& through< mother father ;ast 1no!n Address<
%f your brother/sister had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
/ f you ha!e more than - brothers or sisters, please put their details on the back of this sheet0
DEPARTMENT OF CLINICAL GENETICS, ,hurchill 'ospital, 6ld 7oad& 'eadington& 6-ford& 689 :;E& cancerA5uestionnaire (v?"9 Mar ?24? )
Tel< 24=>3 ??>2?@ /age E of :
You mothe 's pa ents% $ othe s an" siste s
$our mother#s mother (full name) Maiden name Date of birth Alive Deceased %f not alive& date of death ;ast 1no!n Address 'er age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n) %f your mother*s mother had cancer B +here !as the cancer (eg left breast)
$our mother#s $ather (full name) Date of birth< Alive Deceased %f not alive& date of death< ;ast 1no!n Address<
%f your mother*s father had cancer B +here !as the cancer 'is age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our mother#s %rother or sister#s name Date of birth< Male Demale Alive Deceased %f not alive& date of death< Dull brother/sister 'alf brother/sister %f half& through< mother father ;ast 1no!n Address<
%f your mother*s brother/sister had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our mother#s %rother or sister#s name Date of birth< Male Demale Alive Deceased %f not alive& date of death< Dull brother/sister 'alf brother/sister %f half& through< mother father ;ast 1no!n Address<
%f your mother*s brother/sister had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
/ f your mother has more than , brothers or sisters, please put their details on the back of this sheet0
DEPARTMENT OF CLINICAL GENETICS, ,hurchill 'ospital, 6ld 7oad& 'eadington& 6-ford& 689 :;E& cancerA5uestionnaire (v?"9 Mar ?24? ) Tel< 24=>3 ??>2?@ /age 3 of :
You &athe 's pa ents% $ othe s an" siste s
$our $ather#s mother (full name) Maiden name Date of birth Alive Deceased %f not alive& date of death ;ast 1no!n Address 'er age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n) %f your father*s mother had cancer B +here !as the cancer (eg left breast)
$our $ather#s $ather (full name) Date of birth< Alive Deceased %f not alive& date of death< ;ast 1no!n Address<
%f your father*s father had cancer B +here !as the cancer 'is age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our $ather#s %rother or sister#s name Date of birth< Male Demale Alive Deceased %f not alive& date of death< Dull brother/sister 'alf brother/sister %f half& through< mother father ;ast 1no!n Address<
%f your father*s brother/sister had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
$our $ather#s %rother or sister#s name Date of birth< Male Demale Alive Deceased %f not alive& date of death< Dull brother/sister 'alf brother/sister %f half& through< mother father ;ast 1no!n Address<
%f your father*s brother/sister had cancer B +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
/ f your father has more than , brothers or sisters, please put their details on the back of this sheet0
DEPARTMENT OF CLINICAL GENETICS, ,hurchill 'ospital, 6ld 7oad& 'eadington& 6-ford& 689 :;E& cancerA5uestionnaire (v?"9 Mar ?24? ) Tel< 24=>3 ??>2?@ /age > of :
Othe a&&ecte" elati#es #lease say exactly how each person is related to you e.". mother$s mother$s father /not 1"reat "randfather2 as this could also be your mother$s father$s father, or father$s mother$s father etc.0 mother$s sister$s dau"hter /please do not say 1cousin2 0
Dull Name Date of birth Male Demale Alive Deceased %f not alive& date of death 'o! is this person related to you# ;ast 1no!n Address< +here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
Dull Name Date of birth Male Demale Alive Deceased %f not alive& date of death 'o! is this person related to you# ;ast 1no!n Address<
+here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
Dull Name Date of birth Male Demale Alive Deceased %f not alive& date of death 'o! is this person related to you# ;ast 1no!n Address<
+here !as the cancer (eg left breast) Age !hen cancer found 'ospitals !here treated (Cname of specialist if 1no!n)
/#lease feel free to use extra sheets if you need them0
DEPARTMENT OF CLINICAL GENETICS, ,hurchill 'ospital, 6ld 7oad& 'eadington& 6-ford& 689 :;E& cancerA5uestionnaire (v?"9 Mar ?24? )
Tel< 24=>3 ??>2?@ /age : of :
