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In the questionnaire below, please check all that apply and calculate the numbers in parentheses. If your score is 2 or greater you may be eligible for genetic counseling and possible genetic testing for a hereditary cancer syndrome.

Have you ever had any of the cancers or medical history?


  • Check if Yes:  (2)

  • Check if Yes:  (2)

  • Check if Yes:  (2)

  • Check if Yes:  (2)

  • Check if Yes:  (1)

  • Check if Yes:  (1)


  • Check if Yes:  (2)

  • Check if Yes:  (2)
  • Check if Yes:  (2)

 If you totaled 2 or more, , fill out the form below & submit.