Hereditary Cancer Assessment Questionnaire
Have you or a family member ever had cancer?
Yes
No
I have not had cancer, but I'm not sure about my family members.
Thank you
Based on your response, it might be helpful to speak with someone to help determine whether genetic testing is right for you.
Thank you
Based on your response, genetic testing is unlikely to be of benefit to you at this time.
Thank you
Only certain types of cancers are associated with the need for genetic testing. We are going to ask you some questions about the specific types of cancer that may be associated with genetic risk.
What type of cancer(s) did you and/or your family member have?
Ovarian cancer (Females Only)
Pancreatic cancer
Uterine/Endometrial Cancer (Females only)
Prostate cancer that spread to other body parts (Males only)
Breast cancer - MALE
Breast cancer - FEMALE
Colon/colorectal cancer
More than one of the types of cancer listed here occurred on the same side of the family.
A type of cancer not listed here
I don't know / I am not sure which to choose
If you choose "I don't know" please make sure no other boxes are checked.
Thank you
Based on your response, it might be helpful to speak with someone to help determine whether genetic testing is right for you.
Thank you
Based on your response, genetic testing is unlikely to be of benefit to you at this time.
Thank you
Based on your response, genetic testing may be of benefit to you.
Please choose the items that most accurately describes the breast cancer.
It was diagnosed at age 45 or younger.
The same person had breast cancer more than once.
More than 2 people on the same side of the family had breast cancer.
I had the breast cancer and I am of Ashkenazi Jewish ancestry.
None of these apply.
I don't know OR I am not sure which to choose.
If you choose "None" or "I don't know" please be sure no other boxes are checked.
Thank you
Based on your response, genetic testing may be of benefit to you.
Thank you
Based on your response, it might be helpful to speak with someone to help determine whether genetic testing is right for you.
Thank you
Based on your response, genetic testing is unlikely to be of benefit to you at this time.
Please choose the items that most accurately describes the colorectal cancer.
It was diagnosed at age 50 or younger.
In addition to the person with colon cancer, at least 2 other people on the same side of the family also has cancer (of any kind)
None of these apply
I don't know OR I am not sure which to choose.
If you choose "None" or "I don't know" please be sure no other boxes are checked.
Please choose the items that most accurately describes the uterine/endometrial cancer
.
It was diagnosed at age 50 or younger.
In addition to the person with uterine cancer, at least 2 other people on the same side of the family also has cancer (of any kind)
None of these apply
I don't know OR I am not sure which to choose.
If you choose "None" or "I don't know" please be sure no other boxes are checked.
Please choose the items that most accurately describe the breast and colon cancers.
Colorectal cancer was diagnosed at age 50 or younger.
Breast cancer was diagnosed at age 45 or younger.
The same person had breast cancer more than once.
More than 2 people on the same side of the family had breast cancer
I had the breast cancer and I am of Ashkenazi Jewish ancestry.
In addition to the person with the colon or breast cancer, at least 2 other people on the same side of the family also has cancer (of any kind)
None of these apply
I don’t know OR I am not sure which to choose
If you choose "None" or "I don't know" please be sure no other boxes are checked.
Please choose the items that best describe the colon, breast, and uterine cancer.
Colorectal or uterine cancer was diagnosed at age 50 or younger.
Breast cancer was diagnosed at age 45 or younger.
The same person had breast cancer more than once.
More than 2 people on the same side of the family had breast cancer
I had the breast cancer and I am of Ashkenazi Jewish ancestry.
In addition to the person with the colon, breast, and/or uterine cancer, at least 2 other people on the same side of the family also has cancer (of any kind)
None of these apply
I don’t know OR I am not sure which to choose
If you choose "None" or "I don't know" please be sure no other boxes are checked.
Please choose the items that best describe the breast and uterine cancers.
Uterine cancer was diagnosed at age 50 or younger.
Breast cancer was diagnosed at age 45 or younger.
The same person had breast cancer more than once.
More than 2 people on the same side of the family had breast cancer
I had the breast cancer and I am of Ashkenazi Jewish ancestry.
In addition to the person with the breast or uterine cancer, at least 2 other people on the same side of the family also has cancer (of any kind)
None of these apply
I don’t know OR I am not sure which to choose
If you choose "None" or "I don't know", please make sure no other boxes are checked.
Please select the items that best describe the colon and uterine cancer.
Colorectal or uterine cancer was diagnosed at age 50 or younger.
In addition to the person with the colon or uterine cancer, at least 2 other people on the same side of the family also has cancer (of any kind)
None of these apply
I don’t know OR I am not sure which to choose
If you choose "None" or "I don't know", please be sure no other boxes are checked.
Thank you
Based on your response, genetic testing may be of benefit to you.
Thank you
Based on your response, genetic testing is unlikely to be of benefit to you at this time.
Thank you
Based on your response, it might be helpful to speak with someone to help determine whether genetic testing is right for you.
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