|
A.Patient Parmeters
|
| |
1. |
Presence of Ashkenazi (Eastern European) Jewish ancestry in the family? |
|
|
| |
2. |
Number of women in the family diagnosed with both breast and ovarian cancer? |
|
|
| |
3. |
Number of women in the family diagnosed with ovarian, fallopian tube, or primary peritoneal cancer (in the absence of breast cancer)? |
|
|
| |
4. |
Number of breast cancer cases in the family diagnosed in women under the age of 50? |
|
|
| |
5. |
What is the age of the youngest breast cancer diagnosis in the family? |
|
|
| |
6. |
Presence of mother-daughter breast cancer diagnoses in the family? |
|
|
| |
7. |
How many women with bilateral breast cancer in the family?
(Note: Count women with cancer in both breasts, not two primaries in one breast.)
|
|
|
| |
8. |
Number of men diagnosed with breast cancer in the family? |
|
|
| |
9. |
Presence of pancreatic cancer in the family? |
|
|
| |
10. |
Number of men diagnosed with prostate cancer in the family? |
|
|
|
B. Patient's Information
|
| |
1. |
Patient's first name |
|
NA |
| |
2. |
Patient's last name |
|
NA |
| |
3. |
Patient's age |
|
NA |
| |
4. |
Clinic location |
|
NA |
| C. Adjusted factor considering closest relative with breast cancer:
|
| D. Family side in question:
|
| E. Family and Individual Risk |
| |
Individual |
Family |
| BRCA1 |
NA% |
NA% |
| BRCA2 |
NA% |
NA% |
|