| Question number | Yes | No | |
|---|---|---|---|
| 1 | Do you think that there are any conditions or illnesses that run in your family? If so, please specify:________________ | □ | □ |
| 2 | Have any of your close relatives, including parent(s), children, brother(s), or sister(s), had heart disease (also known as cardiovascular disease, heart attack, angina, bypass surgery) before the age of 60? | □ | □ |
| 3 a | Have any of your close relatives, including parent(s), children, brother(s), or sister(s), had diabetes (also known as type 2 diabetes or non-insulin-dependent diabetes)? | □ | □ |
| 4 | Do you come from any of the following ancestry? People from these backgrounds may be at increased risk of diabetes | ||
| (a) South East Asia | □ | □ | |
| (b) Indian subcontinent, that is, India, Pakistan, Bangladesh | □ | □ | |
| 5 | Have any of your close male relatives, including father, son(s), or brother(s), had prostate cancer before the age of 60? | □ | □ |
| 6 a | Have any of your close female relatives, including mother, daughter(s), or sister(s), had ovarian cancer? | □ | □ |
| 7 | Have any of your close relatives, including parent(s), children, brother(s), or sister(s), had breast cancer before the age of 50? | □ | □ |
| 8 a | Do you have more than one relative who has had breast cancer on either your mother’s or father’s side of the family? Please think about all of the following relatives: parent(s), children, brother(s), sister(s), grandparent(s), aunt(s), uncle(s), niece(s), nephew(s), and grandchildren. | □ | □ |
| 9 | (a) Is your family of Jewish ancestry? | □ | □ |
| (b) If so, are they from Eastern or Central Europe (Ashkenazi)? | □ | □ | |
| People from these backgrounds may be at increased risk of breast cancer | |||
| 10 a | Have any of your close relatives, including parents(s), children, brother(s), or sister(s), had colon or rectal cancer (also known as large bowel or colorectal cancer) before the age of 55? | □ | □ |
| 11 a | Do you have more than one relative who has had colon or rectal cancer on either your mother’s or father’s side of the family? | □ | □ |
| Please think about all of the following relatives: parent(s), children, brother(s), sister(s), grandparent(s), aunt(s), uncle(s), niece(s), nephew(s), and grandchildren. | |||
| 12 | On either of your mother’s or father’s side of the family, thinking about the following relatives: parent(s), children, brother(s), sister(s), grandparent(s), aunt(s), uncle(s), niece(s), nephew(s), and grandchildren, do you have more than one relative who has had: | ||
| (a) Any cancer? | □ | □ | |
| (b) Any of the following types of cancer: brain, kidney, thyroid, stomach, uterus/endometrial, pancreas? | □ | □ | |
a
Items included in FHQ–6, stage 2: validation stage.