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Three Villages Medical Practice NHS GP Surgery in Stourbridge

Family history of cancer questionnaire

Section

Do you have a family history of cancer? *

Yes

I’m not sure

Do you have any family history of any of the following cancers?

Bowel cancer

Breast cancer

Male breast cancer

Breast cancer gene mutation in first degree

Bronchus cancer

Cancer of the bone

Cancer of the brain

Cancer of the colon

Genetic mutation for hereditary nonpolyposis colon cancer

Colorectal cancer

Cancer of genital system

Cancer of the hematopoietic system

Cancer of the ileum

Cancer of the kidney

Liver cancer

Lung cancer

Non-leukaemic lymphatic cancer

Oesophagus cancer

Pancreatic cancer

Prostate cancer

Skin cancer

Stomach cancer

Cancer of the testicle

Tracheal cancer

Cancer of urinary bladder

Cancer of the uterus

Cancer of the uterine cervix

Cancer of the vagina

Select all that apply.

If you are human, leave this field blank.

Stourbridge Health and Social Care Centre
John Corbett Drive
Stourbridge
DY8 4HZ

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01384 987740

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