The first step in understanding and being proactive about your personal cancer risk is knowing your family history. These questions clarify whether an evaluation with a cancer risk expert may be beneficial.

 

This form should not be used for urgent care matters or potentially life threatening conditions. In those situations, please contact 911 or head to the nearest Instacare or emergency room.

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Have you or a family member on either side of the family been diagnosed with:
Breast cancer before age 50?


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Three or more breast cancers on the same side of the family (including yourself)?


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A gene mutation related to cancer (e.g. BRCA1, BRCA2)?


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Any ovarian cancer, pancreatic cancer, or male breast cancer?


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Prostate cancer that spread to other body sites (metastasized)?


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Three or more prostate cancers on the same side of the family (including yourself)?


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Colon or uterine cancer before age 50?


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Two or more colon/rectal, uterine, stomach, pancreas, small bowel, biliary, or brain cancers on the same side of the family (including yourself)?


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Ten or more colon polyps in the same person?


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Three or more people with melanoma on the same side of the family (including yourself)?


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Any breast or prostate cancer in a family of Ashkenazi Jewish heritage?


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Have you ever had a breast biopsy that showed atypical cells (ADH, ALH) or lobular carcinoma in situ (LCIS)?


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If you answered YES to any of these questions, we recommend speaking with a genetic counselor about your personalized options for cancer screening and risk-reduction.
Would you like a genetic counseling assistant to contact you?

If you answered yes to having a genetic counselor contact you, please provide your phone number.