Hereditary cancer risk

Mgr. Hereditary Cancer Risk Assessment Program Please print the forms and mail to Mary Gutowski-Futch RN, MSN
Feist-Weiller Cancer Center
LSUHSC-Shreveport
1501 Kings Hwy
Shreveport, LA. 71130
Thank you for your interest in the Hereditary Cancer Risk Assessment Program (HCRAP). If you would like to participate, complete the attached family history and risk factor questionnaire. Mail completed forms to: Mary Gutowski-Futch RN, MSN at above address. Your first appointment will include a consultation with the Genetic Educator. The Genetic Educator will discuss the program, review your medical and family history and discuss significant risk factors. You will learn about genes, inheritance, genetic testing and monitoring options. The first appointment will take approximately 1 to 1 ½ hours. Additional information may be obtained. This may include obtaining mammography reports, pathology reports, or confirming a history of cancer in the family by obtaining medical records. Assistance will be provided in obtaining all necessary information. Suitability for your participation in specialized early detection studies will be discussed. Name: _________________________________________________________ Address: _______________________________________________________ ____________________________________________________________________ (City) (ST) (Zip) Phone No: Home: __________________________ Work: ________________________ (Area code) (Number) (Area code) (Number) Email address: ___________________________________________________ Birth date: ____________ Social Security No: _________________________ Spouse Name (optional) ____________________________________________ (This is only for purpose of building family tree) When is the best time to contact you? ________________________________ Who referred you to the Hereditary Cancer Risk Assessment Program? _____________________________________________________________ You, Your Parents & Your Grandparents Your Aunts and Uncles (Mother’s Side) (in order) You’re Aunts & Uncles (Father’s Side) (in order) Nieces & Nephews (Children of Your Brothers & Sisters) Personal Risk Assessment
White Black Hispanic Asian Middle Eastern (can indicate certain risks) If you are multi-racial, check all Ashkenazi Jewish European or other country descent : What country? _________________ What generation? _________________ (parents, grandparents, great grandparents) Elementary School Middle School High School Some College College Degree Graduate Degree your menstrual periods became regular? Are you experiencing any Yes No symptoms such as hot • If yes, how many years? _______years if yes, indicate what medication you used: • If yes, what age did you start? ___ How many years have you smoked? ___ How many packs per day? ____ • Do you still smoke? ___ how many packs per day? ___ • if yes, how many drinks per week do you consume? #_____ • If yes, what kind of breast problems have you had? • If yes, how many have you had? #_______ • indicate what hospital(s) you went to for the biopsy(s) • what was the result(s) of the biopsy? Other surgery: _________________________ Chemotherapy- type:______________________ Radiation therapy Other ________________________________ If yes, how often? _______________________ about performing breast self-exam? Do you have any ongoing Briefly describe any health problems here: heart disease, multiple sclerosis, osteoporosis, or any other conditions? Do you take medications What concerns would you like to address during your visit to the Hereditary Cancer Risk Program?

Source: http://www.feistweiller.org/clientuploads/Genetic%20Counseling/HCRAP-program%20form.pdf