Parker Adventist Hospital Genetic Counseling Family History Questionnaire
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- Mildred Day
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1 PATIENT NAME: To be completed by Questionnaire received: Genetic Counseling Clinic: Parker Adventist Hospital Genetic Counseling History Questionnaire Appointment: You have been referred to Genetic Counseling Clinic (GCC) at Parker Adventist Hospital due to your personal or family history of a possible or diagnosed genetic disease. Prior to your appointment, you will called by a Health Benefits Advisor to verify your insurance coverage and appointment cost. Self-pay discounts are available, if needed. At GCC you will meet with a genetic counselor, Melissa Gilstrap, MS, CGC. The goal of genetic counseling is to help you learn more about hereditary causes of disease and how y may affect you. At appointment you will discuss your family and personal history and wher or not genetic testing may be beneficial for you or your family members. If you receive genetic counseling, you are under no obligation to pursue genetic testing. If you decide to pursue genetic testing, you may eir have your sample (blood or saliva) collected immediately following your appointment or prior authorization will be obtained from your insurance company and you will return to Parker Adventist Hospital to have your sample collected at a later date. Please take your time to complete attached questionnaire to best of your ability. A review of your family and personal history is necessary to provide you with an accurate risk assessment and to determine wher or not genetic testing could aid in risk assessment for you and/or your or family members. Please arrive 10 minutes early for your appointment so that you can check in with front desk and sign appropriate paperwork. If you need to cancel an appointment, please call at least 48 hours in advance. Prior to your appointment, please mail, fax, or your completed questionnaire to: Melissa Gilstrap, MS, CGC Genetic Counseling Clinic Parker Adventist Hospital Cancer Center 9395 Crown Crest Blvd. Parker, CO Fax: MelissaGilstrap@centura.org NOTE: If you or one of your close relatives has already received cancer genetic counseling or cancer genetic testing, you may not need to complete this entire questionnaire. Instead, please send following: 1) Pages 1-4 of this questionnaire 2) A copy of family history, consultation summary, and/or genetic test results for you or your relative(s) Instructions for completing questionnaire: 1) Please answer all questions and fill out all columns as completely as possible. 2) Please record ALL RELATIVES (even if y have not had cancer or anor disease) 3) Please give as much information as possible about current ages, ages at, and ages of diagnosis of disease. Approximate ages are better than not listing ages at all. This information is needed for an accurate risk assessment to be performed. 4) Write UNK (unknown) if you do not know or NA (not applicable) if information requested does not apply. 5) If individuals have had colon polyps, please number of polyps y had and which y were found. 6) If females have had ir ovaries removed, please write at what age this surgery took place. If you have any questions, please call Melissa Gilstrap at February of 9
2 PERSONAL INFORMATION: Name: Address: Date of birth: : Telephone: Home: Work: Cell: In order to protect your privacy, please indicate how we may contact you: By phone at home? By cell phone? By phone at work? By mail? By ? May we send your visit notes via ? Yes No Ancestry/race/ethnicity (please mark all that apply): White/Caucasian Latina/Latino/Hispanic African American/Black Asian/Asian American Native American/Alaskan Native Multiracial Or (specify): If known, please list specific countries where your distant ancestors originated: Far s side: Mor s side: Because some health conditions occur more frequently in certain Jewish populations, please answer se questions: Is your far or are his ancestors Ashkenazi Jewish? Unsure Is your mor or are her ancestors Ashkenazi Jewish? Unsure To aide in cancer risk assessment: Number of colonoscopies or sigmoidoscopies you have had? Were any polyps found? Unsure If yes, how many polyps were found? Polyps found at what age? For women only: Age at your first menstrual period: Height: Weight: Number of breast biopsies you have had? Have any breast biopsies revealed atypical hyperplasia? Unsure Have any biopsies revealed lobular neoplasia? Unsure If so, at what age was lobular neoplasia diagnosed? Age at first childbirth: t applicable Ovaries removed: Age that ovaries were removed: Check one: Premenopausal Perimenopausal Postmenopausal Age at menopause: Hormone replacement rapy use: Never Current user Number of yrs used: More than 5 yrs ago Less than 5 yrs ago Health issues you have had: Surgeries/biopsies you have had: INSURANCE INFORMATION: Please fill out information below or return a copy of your insurance card with this questionnaire Insurance company: Name of subscriber (if or than self): Subscriber s date of birth (if or than self): REFERRING PHYSICIAN INFORMATION: Name: Phone number: Practice name: February of 9
3 IMMEDIATE FAMILY: Cause of Example: Cousin Jane Doe 68 Breast Cancer Arthritis 30 UNK Heart Attack You Yes Spouse Children (if your children have different parents, please parent s name in ne Far Male Mor Female Brors and Sisters (if you have half siblings, please indicate shared parent in ne February of 9
4 IMMEDIATE FAMILY (continued): Cause of Nieces and Nephews (please name of your bror or sister, who is parent, in ne Grandchildren (please name of your child, who is parent, in ne February of 9
5 FATHER S SIDE OF FAMILY: Grandfar Grandmor Aunts and Uncles (if your aunts and uncles have different parents, please parent that is shared in ne Male Female Cause of Cousins (please name of your aunt or uncle, who is parent, in ne February of 9
6 MOTHER S SIDE OF FAMILY: Grandfar Grandmor Aunts and Uncles (if your aunts and uncles have different parents, please parent that is shared in ne Male Female Cause of Cousins (please name of your aunt or uncle, who is parent, in ne February of 9
7 ADDITIONAL FAMILY MEMBERS: Please use this space to provide information on additional family members that you did not have space for on previous pages. Make as many copies of this page as you need. NOTE: Please make sure to provide how each person is related to you and if y are on your mor s or far s side of family. Cause of February of 9
8 Melissa Gilstrap, MS, CGC Certified Genetic Counselor Phone: Fax: Authorization to Disclose My Genetic Consultation and/or Genetic Test Results Patient Name: Date of Birth: I authorize Parker Adventist Hospital Genetic Counseling Clinic to disclose genetic consultation notes and/or genetic test results to my care team and following physicians or persons: 1. My address on file This authorization is permanent unless orwise noted here: Patient or legally authorized individual signature Date Printed name if signed on behalf of patient Relationship (parent, guardian, personal representative, etc) February of 9
9 KEEP THIS PAGE FOR YOUR APPOINTMENT My appointment date: My appointment time: ***Please arrive 10 minutes early for your appointment so that you can check in with Cancer Center front desk and sign appropriate paperwork.*** ***If you need to cancel an appointment, please call at least 48 hours in advance.*** The Genetic Counseling Clinic meets in Cancer Center at Parker Adventist Hospital. Hospital Address: 9395 Crown Crest Blvd. Parker, CO Cancer Center phone number: Genetic Counselor: Melissa Gilstrap, MS, CGC Phone number: The Genetic Counseling Clinic is located in Parker Adventist Hospital Cancer Center. Walk in Cancer Center entrance and turn to your right. Here you will be greeted and checked in for your appointment. February of 9
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