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  • HBOC Family History Collection Tool

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    National Coalition for Health Professional Education in Genetics
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    A tool to help health care providers collect family history information to be able to assess underlying genetic risk. This fact sheet was developed by NCHPEG as part of the educational program, Hereditary Breast and Ovarian Cancer: Is your patient at high risk? (www.nchpeg.org/hboc)

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    A tool to help health care providers collect family history information to be able to assess underlying genetic risk. This fact sheet was developed by NCHPEG as part of the educational program, Hereditary Breast and Ovarian Cancer: Is your patient at high risk? (www.nchpeg.org/hboc)

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    803 views4 pages

    HBOC Family History Collection Tool

    Uploaded by

    National Coalition for Health Professional Education in Genetics
    A tool to help health care providers collect family history information to be able to assess underlying genetic risk. This fact sheet was developed by NCHPEG as part of the educational program, Hereditary Breast and Ovarian Cancer: Is your patient at high risk? (www.nchpeg.org/hboc)

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 4

    Hereditary Breast & Ovarian Cancer Program

    Family History Collection


    FAMILY HISTORY COLLECTION TIPS
    Use the attached forms to capture family cancer history. First determine who is in the family. Include at least parents, children, siblings, grandparents, aunts/uncles and first cousins. Expand to more distant relatives when it will help clarify patterns, or when there is an exceptional cancer history, such as very early age of onset or rare cancers. Once you have determined family structure, ask about cancer history. When time permits, consider including other notable family history, such as birth defects, distinctive physical features, and intellectual disability or autism. Family structure: Verify relationships, including half and step siblings, adopted individuals, and assisted reproduction with donor gamete. Ask about both paternal and maternal sides of the family Include unaffected and deceased relatives which can modify risk calculations by a genetics professional Dont forget to ask about ancestry When possible, clarify the location and type of cancer Ask about the presence of bilateral disease or multiple primary tumors Indicate approximate ages of diagnosis and death Indicate whether significant environmental risk factors are present. Dont forget to ask about cancers other than breast and ovarian Assess the familys level of certainty about the diagnosis (ie. are they sure it was ovarian cancer and not cervical or another female cancer?)

    Disease expression:

    FAMILY HISTORY RESOURCES


    Collection Tools NCHPEG Family History Form: http://www.nchpeg.org/index.php?option=com_content&view=article&id=61&Itemid=74 Surgeon General's Family Health History: http://www.hhs.gov/familyhistory/ American Medical Association Genetics Family History Form: http://www.amaassn.org/resources/doc/genetics/adult_history.pdf Pedigree Drawing Software KUMC Clearinghouse of Pedigree Drawing Software: http://www.kumc.edu/gec/prof/genecomp.html#pedigree Tips and guidance for family history collection and pedigree drawing NCHPEG Family History Educational Aids: http://www.nchpeg.org/index.php?option=com_content&view=article&id=145&Itemid=64 American Medical Association: http://www.ama-assn.org/resources/doc/genetics/family_history02.pdf

    Published September 2013 NCHPEG All rights reserved

    FAMILY HISTORY QUESTIONNAIRE


    Documented By: Maternal Family (Biological) Ethnic Background:
    If Living Current Age If in Good Health Relationship Grandmother Grandfather Aunt(s) Uncle(s) 1) Cause of death 2) Age at death 3) Health problems

    Date:

    Historian: Paternal Family (Biological) Ethnic Background:


    If Living Current Age If in Good Health Relationship Grandmother Grandfather Aunt(s) Uncle(s) 1) Cause of death 2) Age at death 3) Health Problems

    Biological Mother
    If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

    Biological Father
    If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

    Sisters
    If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

    Brothers
    If Living If in Good Health Name and current age if living 1)Cause of death 2) Age at death 3) Health problems

    Daughters
    If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

    Sons
    If Living If in Good Health Name and current age if living 1) Cause of death 2) Age at death 3) Health problems

    Indicate whether adopted, half-siblings, and mono- or di-zygotic twins.

    Published September 2013 NCHPEG All rights reserved

    Other Maternal Relatives of Concern


    If Living Current Age If in Good Health Relationship 1) Cause of death 2) Age at death 3) Health problems

    Other Paternal Relatives of Concern


    If Living Current Age If in Good Health Relationship 1) Cause of death 2) Age at death 3) Health Problems

    Published September 2013 NCHPEG All rights reserved

    Published September 2013 NCHPEG All rights reserved

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