Family History Questionnaire
McDowell Mountain
Gynecology Office
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Welcome to McDowell Mountain Gynecology! Here, we strive to make your experience as smooth as possible. Below, you'll a fillable form for your convenience, including medical history and family questionnaires.
We also accept various insurances, ensuring accessibility to our services. Please review our insurance and financial policies, and don't hesitate to contact us with any questions.
Please complete the following form and submit it when done
This is a Screening tool for the common features of hereditary cancer syndromes. If you circle Y (yes) for any statement below, you may be appropriate for hereditary cancer testing. Please note all 1st, 2nd and 3rd degree relatives. Mother/Father/Sister/Brother/Children = 1st Degree Relatives Aunt/Uncle/Grandparent/Niece/Nephew = 2nd Degree Relatives Cousin/Great Grandparent = 3rd Degree Relatives
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