This form will help you start a conversation with your family and collect information about cancer in your family.
Most genetic counseling offices will have a more detailed family history questionnaire that may or may not be required to be completed prior to your visit. It can be helpful to collect your family history information before meeting with a genetics provider.
Why Should You Know Your Family History of Cancer?
A family history of cancer might mean you are at risk for developing certain hereditary cancers, including breast, ovarian, colon and pancreatic cancer. This could be because of an inherited change in your DNA, lifestyle choices or other factors. Knowing your family history of cancer can help to understand risk.
What Should You Do Once You Have Finished Your Family History Form?
Print this page and take this form to your healthcare provider or a licensed, genetic counselor to discuss your family history of cancer and your risks of hereditary cancer. Genetic counseling is the process of helping people understand their hereditary risk of cancer, while also offering support and resources for patients and families.
Resources and Education on BRCA Hereditary Cancers
The Basser Center for BRCA provides information on risk evaluation for hereditary cancers and the genetic counseling and testing process.
Family History Intake Form Directions
Fill out this form to the best of your ability. Some important information is the type of cancer and age at diagnosis. If you do not know exact dates, give an estimate.
Schedule an Appointment at Penn Medicine
To schedule an appointment for genetic risk evaluation or management of hereditary cancer risks at Penn Medicine:
- If new to Penn Medicine: call the New Patient Office at 215-615-5858
- Once you are registered or if you are an existing Penn Medicine patient, please contact the MacDonald Cancer Risk Evaluation Center at 215.349.9093 or CREPteam@pennmedicine.upenn.edu.
Find a Genetic Counselor in Your Area
To find a genetic counselor in your area, visit the National Society of Genetic Counselors or contact your local academic medical center.
Find an NCI-Designated Cancer Center in Your Area
To find an NCI-Designated Cancer Center near you and to learn more about each center's specific research capabilities and programs, including clinical cancer genetics programs, visit the National Cancer Institute. In addition, many teaching hospitals and larger community hospitals have clinical genetics programs.