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Family Tree Information

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Patient Information

Full Name *

Age *

Gender *

Cancer Information

Do you have cancer/tumor disease?

Yes

If any diagnosis?

Date of diagnosis and first diagnosis of cancer/tumor disease (month/year):

Spouse Information

How old is your spouse?

Are you related to each other?

Yes

children

How many daughters do you have? How old are they?

How many sons do you have? How old are they?

Mother Information

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Father Information

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Parental Kinship

Are your parents related?

Yes

Aunts (1-3)

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Uncles (1-3)

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Aunts (1-3)

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Uncles (1-3)

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

Year of Birth or Age?

Do they have cancer/tumor disease?

Yes

If any diagnosis?

The Date or Age of the First Diagnosis?

cousins

Do they have cancer/tumor disease?

If any diagnosis?

The Date or Age of the First Diagnosis?

Do they have cancer/tumor disease?

If any diagnosis?

The Date or Age of the First Diagnosis?

The Unasked Relative

Which relative?

What is the diagnosis?

The Date or Age of the First Diagnosis?

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