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Breast and Ovarian Cancer Risk Assessment Tool

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			-

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.

ATTENTION Primary Care Physicians: If you are not familiar with this Risk Assessment Tool or this form of genetic testing and wish to consult with someone at Tennessee Oncology, please contact Dr. Nancy Peacock at our Baptist Hospital Location (615) 329-0570. You can also obtain information
on our web site www.tnoncology.com.

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

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