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AFCA GENETIC SCREENING
Cancer Medical Qualifying Questionnaire
First Name
Last Name
Address
Address
Street Address Line 2
City/State/Zip
State / Province
Postal / Zip Code
Home Phone
Phone number
Cell Phone
Phone number
Email
example@example.com
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*Please Read the following carefully and check all that apply*
Patient has a PERSONAL history of breast cancer (if yes, select all that apply):
A known mutation in a cancer susceptibility gene within the family
Diagnosed at age 45 years or younger
Diagnosed at age 50 years or younger with:
An additional breast cancer primary
≥1 close blood relative with breast cancer at any age
≥1 close relative with pancreatic cancer
≥ 1 relative with prostate cancer (Gleason score ≥7)
An unknown or limited family history
Diagnosed at age 60 years or younger with triple negative breast cancer
Diagnosed at any age with:
≥1 close blood relative with breast cancer diagnosed ≤50 y
≥2 close blood relatives with breast cancer at any age
≥1 close blood relative with ovarian carcinoma
≥2 close blood relatives with pancreatic cancer and/or prostate cancer (Gleason score ≥7) at any age
A close male blood relative with breast cancer
Personal history of prostate cancer (Gleason score ≥ 7) at any age with:
≥1 close blood relative with ovarian carcinoma at any age
≥1 close blood relative with breast cancer diagnosed at 50 years or younger
two relatives with breast, pancreatic or prostate cancer (Gleason score ≥ 7) at any age
Personal history of pancreatic cancer at any age with:
≥1 close blood relative with ovarian carcinoma at any age
≥1 close blood relative with breast cancer diagnosed at 50 years or younger
two relatives with breast, pancreatic or prostate cancer (Gleason score ≥ 7) at any age
Personal history of ovarian carcinoma (epithelial, non-mucinous histology), fallopian tube and primary peritoneal cancers
Personal history of male breast cancer
Individual of Ashkenazi Jewish descent with breast, ovarian, or pancreatic cancer at any age
BRCA1/2 pathogenic mutation detected by tumor profiling on any tumor in the absence of germline mutation analysis
Personal history of metastatic prostate cancer (radiographic evidence of or biopsy-proven disease)
Individual with a personal and family history of three or more of the following:
Breast cancer, pancreatic cancer, prostate cancer (Gleason score ≥ 7 or metastatic), melanoma, sarcoma, adrenocortical carcinoma, brain tumors, leukemia, diffuse gastric
cancer, colon cancer, endometrial cancer, thyroid cancer, kidney cancer, dermatologic manifestations, and/or macrocephaly, hamartomatous polyps of gastrointestinal (GI) tract
Patient has or had colorectal or endometrial cancer and meets one of the following criteria:
Patient’scolorectaltumorisMSIunstablebyPCRand/ordemonstratingMMRproteindeficiencybyIHC
Patient has a close blood relative with a known Lynch syndrome related pathogenic variant
Patient diagnosed with endometrial cancer ≤50 years
Hereditary colorectal cancer/FAP/AFAP/MAP
Patient with ≥20 cumulative colorectal adenomas over a lifetime
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