Family Health History Worksheet

Breast and ovarian cancers are often linked in families, and understanding your family health history is one of the most important things you can do to protect your health. Collect this information to help identify where you fall on the risk spectrum.

Where to Start

Find out which relatives—on both your parents’ sides, if you’re able—had cancer of any kind, which types, and their age at diagnosis. While breast and ovarian cancer history is important, other types of cancer can also be indicators of genetic risk, so capture everything you can.

  • This information should be discussed with your healthcare provider and may also be shared with your family members.
  • Including as much information as possible will allow your healthcare provider to most accurately assess whether or not you and your family may have increased risk of cancer due to inherited factors.
  • If you do not know an exact cancer type or age of diagnosis, please try to estimate.
Have any of your family members been diagnosed with breast cancer?

Yes    No
If yes, who (name and relation)? Age at diagnosis?

Did the relative have any of the following:

  • Triple negative (ER-, PR-, HER2-) breast cancer
  • More than one breast cancer (cancer in both breasts, or two separate breast cancers in one breast)
  • BOTH breast cancer and another type of cancer? If yes, what type of cancer?
  • Male breast cancer
Have any of your family members been diagnosed with a genetic mutation that increases breast cancer risk?

Yes    No
If yes, who (name and relation)?

Type of mutation?

  • BRCA1 or BRCA2
  • Lynch Syndrome
  • Li-Fraumeni Syndrome (TP53)
  • Cowden Syndrome (PTEN)
  • Hereditary Diffuse Gastric and Lobular (CDH1)
  • Peutz-Jeghers Syndrome (STK11)
  • PALB2
  • CHEK2
  • ATM
  • NBN
  • BARD1
  • BRIP1
  • RAD51C
  • RAD51D
  • Other specific mutation
  • VUS (variant of uncertain significance)
Have any of your family members been diagnosed with ovarian cancer?

Yes    No
If yes, who (name and relation)? Age at diagnosis?

On one side of the family, is there breast and one of the following cancers?

Ovarian Cancer
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Prostate Cancer
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Pancreatic Cancer
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Colorectal Cancer
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Thyroid Cancer
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Sarcoma
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Melanoma
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Stomach Cancer
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Uterine Cancer
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Leukemia or Lymphoma
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Adrenocortical Carcinoma
Yes    No
If yes, who (name and relation)? Age at diagnosis?

Is your family of Ashkenazi (Eastern European) Jewish descent?

Yes    No
If yes, are there any cases of breast, ovarian or pancreatic cancer in the family?
If yes, who (name and relation)? Which cancer(s)?