In association with

Rajiv Gandhi Cancer Institute

and Research Centre, New Delhi

“Care with Excellence”

History Taking Form
PR No:............................................CR No:............................................Date:...................................................................
Name:....................................................................................................Address:..............................................................
Age/Sex:........................................Consultant:...............................................................................................................
History (HOPI including pre treatment and present complaints in chronologic with durations and dates)
General – fever Yes No duration/type _________

weight loss Yes No duration ______________ loss in kg __________

anorexia Yes No duration ______________

weakness Yes No duration ______________

malaise Yes No duration ______________

fatigue Yes No duration ______________

pain Yes No site/duration/intensity/score _________________

loss of sleep

depression
Chest and Respiratory (cough/chest pain/ shortness/hemoptysis/stickyness)

Gastro intestinal and HBP (dysphagia/odynophagia/nausea/vomoiting/jaundice/pain

abdomen/hematemesis/black stool/abdominal distension/early satiety/diarrhea/constipation)

Brain and spine (headache/vomiting/convulsion/vertigo/dizziness/giddiness/visual problem/gait

disturbances)

Bone and muscle (pain/swelling/restricted activities)

Breast and female genital

Urological

Head and neck

Blood and lymph node

Endocrine

Skin

Eye
Surgery (non-operated, operated, residual, recurrent, inoperable, operative finding with date)

Personal History (religion / marital status / education / occupation / tobacco & alcohol use / allergy /
co-existing or previous disease with surgery, treatment, drug / reproductive history)

Chronic disease

Family History (cancer / other)

Go to Risk factors / etiologies section if needed (below)

Carcinoma Cervix

• Human Papilloma virus (HPV 16, HPV18, HPV31, HPV33, HPV45) Yes No DK
• Smoking Yes No
• HIV/AIDS Yes No
• Chlamydia infection Yes No
• Immune status (autoimmune diseases like SLE and RA) Yes No
• Diet low in fruits and vegetables Yes No
• Long time use of OCP Yes No duration___________
• Multiple full term pregnancies Yes No
• Young age at first full term pregnancy Yes No age at pregnancy ________
• Family history of cervical cancer Yes No
• Multiple sexual partners. Yes No
• Women with pre-invasive lesions Yes No
• Women who do not come for regular health check-up and Pap tests Yes No
• Age ___________

Carcinoma lung

• Smoking Yes No duration ________ age at start _______ age at cessation ______
• Occupational exposures
- Asbestos Yes No duration _______________
- Silica Yes No duration _______________
- Diesel engine exhaust Yes No duration _______________
- Mineral oil Yes No duration _______________
- Working as a painter Yes No duration _______________
- Arsenic and inorganic arsenic compounds Yes No duration _______________
- Working as welder (fumes) Yes No duration _______________
• Outdoor air pollution Yes No
• Indoor air pollution (coal, biomass fuel) Yes No
• Family history Yes No
• Previous cancer Yes No
• Previous lung disease
- history of pneumonia Yes No
- history of tuberculosis Yes No
- history of silicosis Yes No
- history of emphysema Yes No
 - history of bronchitis Yes No
• Infections (HIV/AIDS) Yes No
• Immune system
- organ transplant recipient Yes No
- SLE Yes No
• Diet
- Red and processed meat Yes No
- Beta carotene supplement Yes No
• Overweight and Obesity Yes No

Breast cancer

• Age
• Age at menarche _______
• Age at first child birth _________
• Breastfeeding Yes No
• Age at menopause ______
• Oral contraceptives Yes No duration ___________ name hormone __________
• Hormone Replacement therapy Yes No
• Family history and genetic factors Yes No
• Overweight and obesity Yes No
• Benign breast disease Yes No
• In situ breast carcinoma Yes No
• Previous breast cancer Yes No
• Previous other cancer Yes No
• Ionising radiations (x rays and gamma rays) exposure Yes No
• Alcohol Yes No
• Tobacco Yes No

Bowel cancer

• Diet
- Red meat, processed meat (increases risk) Yes No
- Dietary fibre (decreases risk) Yes No
- Garlic, milk, calcium (probably decreases risk) Yes No
- Heam iron, dietary animal fat, cheese, dietary sugar (possibly increases risk) Yes No
- Non starchy vegetables, fruits. Dietary vitamin D (possibly decreases risk) Yes No
• Overweight and obesity Yes No
• Alcohol Yes No
• Tobacco Yes No
 • Medical conditions
- Adenoma/polyp (Around 1% of people with larger (20mm+) adenomas, or adenomas with
high-grade dysplasia, develop bowel cancer within around 4 years of having their adenomas
removed) Yes No
- IBD (ulcerative or Crohn's colitis) Yes No
- type II diabetes Yes No
- metabolic syndrome (characterized by a combination of diabetes, high blood pressure, and
abdominal obesity) Yes No
• Infections
- Human papilloma virus Yes No
- H. Pylori Yes No
- HIV Yes No
• Previous cancer Yes No
• Radiation Yes No
• Family History and genetic factors
- Family history of bowel cancer Yes No
- Familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer
(HNPCC) Yes No

Urinary Bladder cancer

• Tobacco Yes No
• Occupational exposure
- Aromatic amines (aniline dye industries) Yes No
- Poly aromatic hydrocarbons Yes No
- Diesel engine exhaust Yes No
- Hair dye Yes No
- Previous cancers Yes No
• Ionising radiation Yes No
• Medical conditions and treatment
- Chemotherapy Yes No
- Diabetes Yes No
• Infections
- Human papiloma virus Yes No
- Schistosomiasis Yes No
• Family history Yes No
• Diet (high risk factors with respect to diet are:
- Diet low in fruits Yes No
- Diet high in soya food Yes No
- Heavy coffee consumption (>10cups per day) Yes No
• Arsenic exposure Yes No
Hereditary/Familial Cancer:
(All of the people who fall into the categories below warrant for genetic counselling and risk
management advice. )
Some probability for needing germline testing Following Family Cancer Clinic.
Breast cancer under age 35 yrs Yes No
Male breast cancer Yes No
Multiple primary tumours (excluding lung and skin) under age 70 yrs e.g. breast and ovarian, fallopian
tube, primary peritoneal, endometrial and colorectal cancer Yes No
Colorectal cancer under age <40 yrs: Yes No
Rare tumour* under age 45 yrs Yes No
(*Phaeochromocytoma , paraganglioma, sarcoma , glioblastoma , choroid plexus
carcinoma adeno carcinoma , retinoblastoma )
2 or more first degree or second degree relatives on the same side of the family with CRC or endometrial
cancer with one diagnosed under age 60 yrs.
2 or more first degree or second degree relatives on the same side of the family with either breast cancer
under age 60 yrs and/or ovarian cancer at any age;
Rare tumour* any age with close relative with similar tumour:
(*Phaeochromocytoma , paraganglioma, sarcoma , glioblastoma , choroid plexus
carcinoma adenocarcinoma , retinoblastoma )
High probability for needing germline testing.

Blood relative of known BRCA mutation carrier

Yes No

Blood relative of a known carrier of a high risk breast cancer predisposition gene eg BRCA1, BRCA2
Yes No

Blood relative of a known carrier of a high risk colorectal cancer predisposition gene eg APC, MYH, MLH1,
MSH2, MSH6, PMS2
Yes No

Blood relative of a known carrier of other high risk predisposition genes eg TP53, PTEN, VHL, SDHA, B, C or D,
and NF2
Yes No

Personal or family history of breast or ovarian cancer, and Ashkenazi Jewish ethnicity
Yes No

Epithelial ovarian, fallopian tube or primary peritoneal cancer <70 yrs

Yes No

Triple negative breast cancer (TNBC) <40 yrs at diagnosis (TNBC: oestrogen, progesterone and HER2 receptor
negative)
Yes No
 In association with

Rajiv Gandhi Cancer Institute

and Research Centre, New Delhi

“Care with Excellence”

Genetic tests to be advised

Gene Syndrome Relared cancer type

Hereditary breast cancer and Female breast, ovarian, and other cancers, including
BRCA1, BRCA2
ovarian cancer syndrome prostate, pancreatic, and male breast cancer

TP53 Li-Fraumeni syndrome Breast cancer, soft tissue sarcoma, osteosarcoma,

leukemia, brain tumors, adrenocortical carcinoma
and other cancers

PTEN Cowden syndrome (PTEN Breast, thyroid, endometrial, and other cancers
hamartoma tumor syndrome)

MSH2, MLH1, Lynch syndrome (hereditary Colorectal, endometrial, ovarian, renal pelvis,
MSH6, PMS2, nonpolyposis colorectal pancreatic, small intestine, liver and biliary tract,
EPCAM cancer) stomach, brain, and breast cancers

APC Familial adenomatous Colorectal cancer, multiple non-malignant colon

polyposis polyps, and both benign and malignant tumors in
the small intestine, brain, stomach, bone, skin, and
other tissues

RB1 Retinoblastoma Retinoblastoma,pinealoma, osteosarcoma,

melanoma, and soft tissue sarcoma

: MEN1 Multiple endocrine neoplasia Pancreatic endocrine tumors and (usually benign)
type 1 (Wermer syndrome) parathyroid and pituitary gland tumors

RET Multiple endocrine neoplasia medullary, thyroid cancer, pheochromocytoma

type 2

VHL Von Hippel-Lindau syndrome Kidney cancer and multiple noncancerous tumors,
including pheochromocytoma

Who should consider genetic testing for cancer risk?

Genetic testing for cancer risk should be strongly considered when all three of the following criteria are met:
• The person being tested has a personal or family history that suggests an inherited cancer risk
condition
• The test results can be adequately interpreted (that is, they can clearly tell whether a specific genetic
change is present or absent)
• The results provide information that will help guide a person’s future medical care

The features of a person’s personal or family medical history that, particularly in combination, may
suggest a hereditary cancer syndrome include:
• Cancer that was diagnosed at an unusually young age
• Several different types of cancer that have occurred independently in the same person
• Cancer that has developed in both organs in a set of paired organs, such as both kidneys or both breasts

All of the people who fall into the categories below warrant for genetic counselling and risk management
advice.
The categories highlighted by ## have a high probability of being offered germline testing.
Those highlighted by # may be offered germline testing following review by a Family Cancer Clinic.

GENERAL PRACTITIONERS

Individual characteristics

Breast cancer under age 35 yrs #

Male breast cancer #

Multiple primary tumours (excluding lung and skin) under age 70 yrs e.g. breast and ovarian,
#
fallopian tube, primary peritoneal, endometrial and colorectal cancer

Colorectal cancer under age 40 yrs #

Rare tumour* under age 45 yrs #

Family history characteristics

##
Blood relative of known BRCA mutation carrier

Blood relative of a known carrier of a high risk breast cancer predisposition gene
##
eg BRCA1, BRCA2

Blood relative of a known carrier of a high risk colorectal cancer predisposition gene eg
##
APC, MYH, MLH1, MSH2, MSH6, PMS2
Blood relative of a known carrier of other high risk predisposition genes eg TP53,
PTEN, VHL, SDHA, B, C or D, and NF2 ##

Personal or family history of breast or ovarian cancer, and Ashkenazi Jewish ethnicity ##

2 or more first degree or second degree relatives on the same side of the family with
#
CRC or endometrial cancer with one diagnosed under age 60 yrs

2 or more first degree or second degree relatives on the same side of the family with
#
either breast cancer under age 60 yrs and/or ovarian cancer at any age

Rare tumour* any age with close relative with similar tumour #

Tumour pathology characteristics

Epithelial ovarian, fallopian tube or primary peritoneal cancer <70 yrs ##

Triple negative breast cancer (TNBC) <40 yrs at diagnosis (TNBC: oestrogen,
##
progesterone and HER2 receptor negative)
*Phaeochromocytoma, paraganglioma, sarcoma, glioblastoma, choroid plexus
carcinoma, adenocarcinoma, retinoblastoma