Family History
Please indicate if any of your family members have a history of the following. Items are listed multiple times to allow for multiple family members.
Breast Cancer
Family Member
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Age when diagnosed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Age when diagnosed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Age when diagnosed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Ovarian Cancer
Family Member
Mother
Daughter
Sister
Grandmother (Mother's Side)
Grandmother (Father's Side)
Great Grandmother (Mother's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Aunt (Father's Side)
Great Aunt (Mother's Side)
Great Aunt (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Age when diagnosed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Mother
Daughter
Sister
Grandmother (Mother's Side)
Grandmother (Father's Side)
Great Grandmother (Mother's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Aunt (Father's Side)
Great Aunt (Mother's Side)
Great Aunt (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Age when diagnosed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Mother
Daughter
Sister
Grandmother (Mother's Side)
Grandmother (Father's Side)
Great Grandmother (Mother's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Aunt (Father's Side)
Great Aunt (Mother's Side)
Great Aunt (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Age when diagnosed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Other Cancer
Type of Cancer
Brain
Breast
Cervix
Colon
Esophagus
Liver
Lung
Lymphoma
Melanoma
Nonmelanoma Skin
Ovary
Pancreas
Prostate
Rectal
Skin
Stomach
Thyroid
Uterus
Other
Family Member
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Type of Cancer
Brain
Breast
Cervix
Colon
Esophagus
Liver
Lung
Lymphoma
Melanoma
Nonmelanoma Skin
Ovary
Pancreas
Prostate
Rectal
Skin
Stomach
Thyroid
Uterus
Other
Family Member
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Type of Cancer
Brain
Breast
Cervix
Colon
Esophagus
Liver
Lung
Lymphoma
Melanoma
Nonmelanoma Skin
Ovary
Pancreas
Prostate
Rectal
Skin
Stomach
Thyroid
Uterus
Other
Family Member
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Other Significant Family History:
No significant family medical history
Adopted / Family history unknown
Women's History
Bra size:
Number
26
28
30
32
34
36
38
40
42
44
46
48
50 or larger
Letter
A
AA
AAA
B
C
D
DD
DDD
E
EE
F
G
other
Last menstrual period:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Age at first period:
n/a
less than 10
10
11
12
13
14
15
16 or more
Date of last pap smear:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Method(s) of contraception:
Depo-Provera
Pill
Foam
Rhythm
Abstinence
Hysterectomy
Tubal Sterilization
Condom
IUD
Vasectomy
None
Other (Please Specify):
Are you pregnant?
Yes
No
Pregnancy due date:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Are you breastfeeding?
Yes
No
Age at first pregnancy:
n/a
less than 16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50 or older
Age at first live birth:
n/a
less than 16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50 or older
Age at menopause:
n/a
less than 20
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50 or older
Do you have a history of hormone replacement therapy?
Yes
No