Ovarian Cancer Risk Assessment

Personal Information

About You

First name *

Last name *

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Date of birth * (mm/dd/yyyy)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Have you Has the patient ever been seen at Roswell Park? Yes No

Patient MRN

How did you hear about Roswell Park?

Please explain *

General Information

Your The Patient's Contact Information

Your Patient's Phone number * (###-###-####)

Alternate phone (###-###-####)

Your Patient's Email Address *

Best time to call

Would you the patient like to join our mailing list? Yes No

Your Patient's Insurance Information Optional

Primary insurance provider

ID number (Letters and Numbers only)

Secondary insurance provider

ID number (Letters and Numbers only)

Your The Patient's Physician Information Optional

Primary physician

Primary physician's phone (###-###-####)

Referring physician

Referring physician's phone (###-###-####)

Risk Assessment

Personal Cancer History

Do youDoes the patient have a personal history of ovarian cancer? * Yes No

Do youDoes the patient have a personal history of breast cancer before the age of 45? * Yes No

Family Cancer & Health History

Do youDoes the patient have a family history of any of the following cancers in a 1^st or 2^nd degree relative (mother, sister or grandmother)? * Ovarian Cancer Fallopian Tube Cancer Primary Peritoneal Cancer No/Unsure

Have any of yourthe patient's male relatives had breast cancer? * Yes No/Unsure

Have youHas the patient or any blood relative tested positive for BRCA1 or BRCA2? * MyselfPatient, BRCA1 MyselfPatient, BRCA2 My Family, BRCA1 My Family, BRCA2 None of the above

Do youDoes the patient have a family history of hereditary nonpolyposis colorectal cancer (HNPCC) in a 1^st or 2^nd degree relative? * Also known as Lynch II, or positive for EPCAM, MLH1, MSH2, MSH6, PMS2 Yes No/Not sure

General Health

In the past month, have youhas the patient had one or more of these symptoms daily for at least 2 weeks? * Bloating or sudden weight loss Urinary frequency Indigestion or feeling full quickly after you begin eating Pelvic or abdominal pain Pelvic pressure None of the above

Your Patient's Residential Address