Screening for Familial Colorectal Cancer Risk amongst Colonoscopy Patients New to an Open-Access Endoscopy Center

Table 1

Hereditary Colorectal Cancer Syndrome Survey (IRB number 23613).

Does anyone in your family have colon POLYPS?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
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Does anyone in your family have COLON or RECTAL cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Does anyone in your family have UTERINE cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Does anyone in your family have STOMACH cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Does anyone in your family have PANCREATIC cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Does anyone in your family have OVARIAN cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
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Does anyone in your family have BRAIN cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Does anyone in your family have URETER/KIDNEY cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Does anyone in your family have SMALL BOWEL cancer?
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Does anyone in your family have any OTHER cancers not listed (ex. Hepatoblastoma, a childhood liver cancer; cancers of the bile duct or gallbladder, etc.)
Relationship to you	Mother or Father’s side of family	Age at diagnosis
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Did one of the following providers refer you for your colonoscopy? If yes, circle the provider. If not, circle other.
McGarrity, Mathew, Ouyang, Riley, Pooran, Rampertab, Smith, Bethards, Schreibman, Meitz, Mukherjee, Downey, Moyer, Biswas, Moole, Thompson, Chase
Other
What is your age?
Have you ever had a colonoscopy before (circle) Yes No
If yes, when
What were the findings:
Why were you referred for today’s colonoscopy?
Have you ever been told that you are at an increased risk for colon or rectal cancer? (circle) Yes No
If yes, reason given to you
Do you have a personal history of these cancers: (circle):
Colon, rectum, uterine, stomach, pancreas, ovarian, brain, gallbladder, ureter/kidney, small bowel, bile duct, breast, thyroid or any other cancers?
Age at diagnosis
Does cancer run in your family? For each individual, list type of cancer, and estimated age when the cancer was found
If person has multiple cancers, please list them all.
	Type of cancer	Age at diagnosis
Mother
Father
Siblings
Grandmother (father’s side)
Grandmother (mother’s side)
Grandfather (father’s side)
Grandfather (mother’s side)
Aunts (indicate mother or father’s side)
Uncles (indicate mother or father’s side)
Nieces or Nephews
Cousins (indicate mother or father’s side)
Your children
Have you been told by your doctor that you may be at increased risk of a hereditary cancer syndrome?		(circle) Yes No
If so, have you been referred to a genetics counselor by your doctor?		(circle) Yes No
If it is determined that your family may be at increased risk for a genetic predisposition to cancer
do you want to be contacted by Dr. Maria Baker, a genetics counselor with the Penn State Cancer Genetics Program?		(circle) Yes No

All information will be kept confidential and not released without your signed permission.