Breast and Ovarian Cancer Risk Assessment Tools

Family History Questionaire for Breast and Ovarian Cancer

Patient Name:	Patient Phone (optional)
Patient Address (optional):	No record of this information is kept by Tennessee Oncology. We respect your privacy.

Please place a check mark in the boxes below, for yourself and for each family member who has had cancer as indicated.

	Breast Cancer Before Age 50	Breast Cancer At or After Age 50	Ovarian Cancer At Any Age
Yourself
Your Mother
Your Sister(s)
Your Daughter(s)
*Mother's Side:*
Grandmother
Aunt(s)
Cousin(s)
*Father's Side:*
Grandmother
Aunt(s)
Cousin(s)
*Father or Mother's Side:*
Any Males with breast cancer at any age			-

If you are a patient of Tennessee Oncology please choose your physician from the list and click the submit button.

If you are not a patient of Tennessee Oncology, please print this form and take it to your primary care physician or your oncologist.

Ask your physician to evaluate your hereditary risk of breast and ovarian cancer if there are:

Two (2) or more check marks in the above table,

OR
One (1) check mark in the above table and you are of Ashkenazi Jewish descent,
OR
Any male relatives with breast cancer at any age.

Note: If the "Print the Questionnaire" button does not work in your browser, you may print by choosing "File" > "Print" from your browser window.