ࡱ>  0bjbj-- OO#z, , 4RRRhRZ<j:p<&&&;;;;;;;$>A;&=&|&&&;< <+++&l(<;+&;++re6T,e7<෍{'6;*<0Z<6@B)(@Be7e7X@B8&&+&&&&&;;)&&&Z<&&&&@B&&&&&&&&&, L:  Please make sure all sections have been completed with as many details as possible. Please review the enclosed instruction sheet for further details about why we are asking for this information. Please return this form either by post or email. If you have an appointment please return this form at least 2 weeks before your appointment, if possible (details above). Please can you also make a copy and bring this to clinic with you, in case it does not reach us in time. You can complete an electronic version of this form which can be found here;  HYPERLINK "https://www.gosh.nhs.uk/clinicalgenetics-appointments" https://www.gosh.nhs.uk/clinicalgenetics-appointments Information about you: Family/Genetics number: Title (Mr / Mrs / Miss etc.)GP Name:First Name:GP Address:Surname:Date of Birth: Address:Your NHS No: (if known)Occupation:Postcode:Email:Mobile Number:Home Telephone: Some types of genetic cancer are slightly more common based on ancestry. What is your ethnicity? __________________________________________________________________________ Is there any Jewish ancestry in your family? ( YES ( NO If yes, on mothers or fathers side? Is there any Polish ancestry in your family? ( YES ( NO If yes, on mothers or fathers side? Have you had any form of cancer or pre-cancer yourself? YES ( NO ( If yes, please provide further details:Type of cancer:Age of diagnosis:Hospital treated / consultant name: Have you or any family member been seen by a Genetics department in the past? YES ( NO ( If yes, please provide further details: Name of relative that was seen by genetics:Their date of birth:Hospital or service where they were seen:Their reference number (if known): What are the main questions you would like to discuss with the Genetics Consultant/Counsellor?  Please complete the form below, giving as much information as possible about your immediate (blood) relatives. It is important to include those family members (alive AND deceased) who have had AND those who have not had cancer, as this will affect your overall cancer risk. For further guidance please see enclosed instructions sheet. Relative Full Name including maiden and any previous names Address inc postcode, or town/city if unknown (even if this person has died)Date of Birth or approx year if unknown Alive Y/NDate of death or approx year if unknownIf your relatives have/had cancer Type of Age at Hospital where treated Cancer diagnosis (town/city if unknown) Your motherYour fatherYour own children please state if male (M) or female (F)Your own brothers & sisters please state if male (M) or female (F) AND If full or half siblingAny comments regarding any of these relatives: Relative Full Name including maiden and any previous names Address inc postcode, or town/city if unknown (even if this person has died)Date of Birth or approx year if unknown Alive Y/NDate of death or approx year if unknownIf your relatives have/had cancer Type of Age at Hospital where treated Cancer diagnosis (town/city if unknown) Your mothers motherYour mothers fatherYour mothers brothers and sisters please state if male (M) or female (F) AND If full or half siblingYour fathers motherYour fathers fatherYour fathers brothers and sisters please state if male (M) or female (F) AND if full or half siblingAny comments regarding any of these relatives: Additional Information: Have you had any cancer screening such as mammography or colonoscopy? YES ( NO ( If yes, please provide further details: Other relatives diagnosed with cancer. Please say exactly how each person is related to you. For example please see enclosed Instructions sheet. Relative e.g. mothers, sisters daughterFull Name including maiden and any previous names please state if male (M) or female (F) Address inc postcode, or town/city if unknown (even if this person has died)Date of Birth or approx year if unknown Alive Y/NDate of death or approx year if unknownIf your relatives have/had cancer Type of Age at Hospital where treated Cancer diagnosis (town/city if unknown)  Type of screening:How often:Hospital and consultant: Last date performed: Current Height:Current Weight: Have you ever smoked tobacco? YES, Currently ( YES, Previously ( NO ( Are your parents blood related, for example, cousins? YES ( NO ( How much alcohol do you drink in the average week e.g. 2 glasses of wine, 2 pints of beer: _______________________________________________ For female patients: (please complete, if applicable, as these factors may influence your risk assessment) Age of first menstrual period:Age at menopause, if applicable: Did/Do you breast feed your children? YES ( NO ( Did/Do you use the oral contraceptive pill? YES in the last 2 yrs ( YES over 2 yrs ago ( NO never ( If YES for how long _______________ Did/Do you use HRT? YES currently ( YES in the past ( NO never ( If YES for how long ________ Type of HRT _______________________  Cancer Genetics Service Instruction Sheet Why have I been sent this form? You have been referred to the Cancer Genetics Service because of a personal and/or family history of cancer. For most families, cancers will be due to chance and other people in the family have no higher risk of developing cancer than the general population. However, a small proportion of cancers are due to an inherited predisposition. We would be grateful if you would complete the attached questionnaire which will be able to help us assess whether or not your family history places you or your relatives at an increased risk of cancer. If you are unable to complete all the sections, please return the form anyway. If you have any queries or difficulties in completing the questionnaire, please do not hesitate to contact us, our details are in the box above. You can also access an electronic version of the form here:  HYPERLINK "https://www.gosh.nhs.uk/clinicalgenetics-appointments" https://www.gosh.nhs.uk/clinicalgenetics-appointments and email this to us on  HYPERLINK "mailto:gos-tr.ClinicalGenetics@nhs.net" gos-tr.ClinicalGenetics@nhs.net. How should I fill in the form? Please attempt to complete as many sections as possible. The more details you can provide, the more accurate we can be in our assessment. It is important to include those family members (alive AND deceased) who have had, as well as those who have not had cancer, as this will affect your overall cancer risk. What if I do not know all the details? If there is any information you do not know, perhaps someone in your family will be able to help you. Otherwise leave that box empty or write unknown. All the information you give will be held in confidence in the Clinical Genetics Unit. Examples for Other relatives section: For other relatives diagnosed with cancer, please say exactly how each person is related to you. E.g.: mothers mothers father (please do not say great-grandfather because this could be your mothers fathers father or your fathers mothers father, etc.) fathers sisters daughter (please do not say cousin) (if in this example father had several sisters, please state which one) What do we do with this information? Sometimes further details about some types of cancer are needed. We can access this information via the cancer registries for relatives who are deceased but we would need permission from living relatives. If we need this information from a living relative, we will contact you with a consent form that you can then pass to your relative. We will not contact your relative directly. The more details about your relatives you provide (such as date of birth and where they were living when they had cancer), the more likely it will be that the registry will be able to locate the records. This will allow us to assess your risk more accurately. What happens next? Our cancer team of genetic counsellors and consultants will assess the information you provide to see if your personal risk of developing cancer in the future is increased. We may contact you if we need further information. Once we have all the needed information we will contact you to either arrange an appointment or discuss the next steps. If you are not at high risk we will not be able to see you in clinic but we will write to you explaining this and, if applicable, recommend screening. If you already have an appointment Please return form at least 2 weeks before your appointment so that we may review and, if needed, request further information.     Information about your relatives Version 5 dated 30/09/2016 Page  PAGE 2 of  NUMPAGES 6 North East Thames Regional Genetic Service Cancer Genetic Service Page  PAGE 1 of  NUMPAGES 5 Version 6 dated 03/02/2020 Page  PAGE 2 of  NUMPAGES 5 Version 6 dated 03/02/2020 If you require more space, please use an extra sheet Clinical Genetics Unit, Great Ormond Street Hospital for Children NHS Trust Great Ormond Street, London WC1N 3JH, Telephone: 020 7762 6831  HYPERLINK "http://www.google.co.uk/imgres?imgurl=http://www.labourlist.org/uploads/f739f314-531d-9734-6de5-bff8b28e0147.jpg&imgrefurl=http://www.labourlist.org/the-end-of-the-nhs-as-we-know-it&usg=__rHjP-7E6YbvdimOQAiyxeioBe3Q=&h=286&w=705&sz=21&hl=en&start=2&zoom=1&tbnid=4spiojXKHDSolM:&tbnh=57&tbnw=140&ei=ttIaTuHyDMK58gPx3NEB&prev=/search%3Fq%3Dnhs%26um%3D1%26hl%3Den%26sa%3DN%26rlz%3D1R2ADRA_enGB425%26tbm%3Disch&um=1&itbs=1"  INCLUDEPICTURE "http://t2.gstatic.com/images?q=tbn:ANd9GcSJWsjrzlzNKLHmecuu98fL1q-P2BBCQr-WHvnU9yraEI282eTCY0Ds00M" \* MERGEFORMATINET  North East Thames Regional Genetics Service Clinical Genetics Unit Great Ormond Street Hospital for Children NHS Trust Great Ormond Street, London WC1N 3JH, Telephone: 020 7762 6096 / 6831   >]1 2 raP?P.P hv hwCJOJQJ^JaJ hv h BCJOJQJ^JaJ hv h,CJOJQJ^JaJ hv h4pCJOJQJ^JaJ hv hA<CJOJQJ^JaJ&hv hA<5>*CJOJQJ^JaJ&hv h,5>*CJOJQJ^JaJh^)CJOJQJ^JaJh^)OJQJho2}h^)OJQJ^J4jho2}h4SOJQJU^JmHnHsH tH u,jho2}hOJQJU^JmHnHu       $Ifgdr^gd@{^gdP^gd,^gd4p^`^gd2 D Z \ g x y   / 0 1 = ǶǤǓrcUA2hw5CJOJQJ^JaJ&jhw5CJOJQJU^JaJhwCJOJQJ^JaJhP5CJOJQJ^JaJ#h4ph4p5CJOJQJ^JaJh4p5CJOJQJ^JaJ h,h4pCJOJQJ^JaJ#hv h,5CJOJQJ^JaJ hv h BCJOJQJ^JaJ hv h,CJOJQJ^JaJ&hv h,5>*CJOJQJ^JaJ&hv h B5>*CJOJQJ^JaJ= r t u ʶޤzodVD3 ho2}hCJOJQJ^JaJ#ho2}hl5CJOJQJ^JaJh+Sh@{5OJQJ^JhR 5OJQJ^JhF#5OJQJ^Jh+Shr5OJQJ^Jh+Sh,5OJQJ^Jh4pCJOJQJ^JaJ#hPh4p5CJOJQJ^JaJ'h>hw0J5CJOJQJ^JaJ&jhw5CJOJQJU^JaJhw5CJOJQJ^JaJ#hwhw5CJOJQJ^JaJ      ( + 3 9 I N V Y ] ^ d e f g q w оЬЬyj[jJ hR hR CJOJQJ^JaJhR 5CJOJQJ^JaJhp95CJOJQJ^JaJ ho2}hMoCJOJQJ^JaJ&ho2}hMo5CJOJQJ\^JaJho2}hMo5OJQJ^J#ho2}hMo5CJOJQJ^JaJ#ho2}hl5CJOJQJ^JaJho2}hl5OJQJ^J ho2}hCJOJQJ^JaJ ho2}hlCJOJQJ^JaJ    *!! 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