BRCA Family History Questionnaire

If you have family members who have had breast or ovarian cancer, your risk is higher than the general population.

Those with a genetic mutation face up to a 90% lifetime risk for breast cancer and up to a 40% lifetime risk for ovarian cancer.

The first step in determining your risk is collecting detailed information about your family’s history of cancer. We recommend that you download the attached form and use it to record information about both the maternal and paternal sides of your family tree.

A genetic counselor or health care provider can help you to interpret this data.
Based on your family history, a genetic counselor can:

  • conduct a cancer risk analysis,
  • help you to evaluate your options,
  • discuss issues of cost, privacy, and confidentiality,
  • explore the medical and psychosocial implications of genetic testing, and review screening options, and provide support.

As part of our BRCA Awareness Program, the Jewish Genetic Diseases Center of Greater Phoenix holds community-education events where participants have the opportunity to meet briefly with a genetic counselor. If you plan to attend one of these events, please bring a completed family history questionnaire with you. This will enable you to make the most of your time with a genetic counselor and allow for more meaningful questions and answers.

In families without a history of breast or ovarian cancer, breast cancer does not usually occur until after age 40.

In families with a history, the breast cancer often occurs at earlier ages.

For those with a family history that includes a BRCA genetic mutation, counseling is recommended starting at age 25.

If after completing the form, you determine that you have no family history of cancer, you should still remain proactive with your health. Conduct self-exams, talk to a medical provider about appropriate diagnostic screening, and make healthy lifestyle choices.

Most importantly, be aware of your body and do not be afraid to ask questions!

Tips for Completing the Family History Questionnaire

  • Start by talking with your relatives – especially parents, if they are living, and older relatives, who are often good sources of information.
  • Vacations and holidays are good times to collect information. As each generation ages, important information can be forgotten, so don’t delay in collecting important medical histories.
  • Contact relatives who have had cancer and confirm the exact type of cancer and at what age they were diagnosed.
  • If you are adopted, you may be able to learn some of your family history through the parent(s) who adopted you or from adoption agency records.
  • Check birthday books, baby books, family bibles, and death certificates for other clues. Verify medical history whenever possible.
  • Keep your completed document in a safe place and update it every couple of years (or update it at a regular family gathering, such as Thanksgiving).

Download Questionnaire Form (Click Here)