Breast Cancer Genetics Referral Screening Tool

Question 1 of 6

Is there any history of breast or ovarian cancer in your family?

Think about both your mother and father's side of the family.
Include yourself, parents, children, brothers/sisters, aunts/uncles, nieces/nephews, and grandparents.

Include only blood relatives

Yes No / Unknown

Question 2 of 6

Have any women in your family been diagnosed with breast cancer?

Think about both your mother and father's side of the family.
Include yourself, mother, sisters, daughters, nieces, aunts, and grandmothers.

Include only blood relatives

Yes No / Unknown

Tap next grey arrow to proceed.

Yourself (if female)

Mother

Sister(s)
Daughter(s)
Niece(s)

Mother’ s Side Grandmother - mother's mother Aunt(s) - mother's sister(s)

Father’ s Side Grandmother - father's mother Aunt(s) - father's sister(s)

Question 3 of 6

Have any women in your family been diagnosed with ovarian cancer?

Think about both your mother and father's side of the family.
Include yourself, mother, sisters, daughters, nieces, aunts, and grandmothers.

Include only blood relatives

Yes No / Unknown

Question 4 of 6

Have any women in your family been diagnosed with both breast cancer and ovarian cancer?

Think about both your mother and father’s side of the family.
Include yourself, mother, sisters, daughters, nieces, aunts, and grandmothers.

Include only blood relatives

Yes No / Unknown

Question 5 of 6

Are there any men in your family who have had breast cancer?

Include yourself (if male), father, brothers, sons, nephews, uncles, grandfathers

Include only blood relatives

Yes No / Unknown

Self (if male)
Father
Brother(s)
Son(s)

Nephew(s)

Mother’ s Side Grandfather - mother's father Uncle(s) - mother's brother(s)

Father’ s Side Grandfather - father's father Uncle(s) - father's brother(s)

Male breast cancer

Question 6 of 6

Is there any Jewish ancestry (Ashkenazi/Eastern European) in your family?

Mother and/or father’s side (blood relatives only)

Yes No / Unknown

Mother’ s Side

Father’ s Side

Jewish Ancestry