Test Page Clinical Summary Step 1 of 7 14% Do you currently have medicare and/or medicaid?*YesNoDo you have personal history of cancer?*YesNoDo you have family history of cancer (1st, 2nd or 3rd degree relatives)?*YesNo Name* First Last Email Address Phone* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender*MaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Ethnicity*African AmericanAshkenazi JewishCaucasianEast IndianFrench CanadianHispanicMediterraneanMiddle EasternNative AmericanPacific IslanderSephardic JewishSoutheast AsianOther Upload an image of your medicare card.*Upload an image of the back of your medicare card*Upload an image of the front of your ID*Primary Insurance*Policy* AllergiesDate of first Consultation*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What age were you when you were diagnosed with cancer?*List all of the over the counter and prescription medications you are currently taking.* Please describe your personal cancer history.*Number of known blood relatives who either have cancer or had cancer.12345Blood relatives like parents, Siblings, Children, Grandparents, Grandchildren, Aunts, Uncles, Nieces, Nephews, Half-siblings, Greats Aunts, Great Uncles, and Great GrandchildrenRelationship to youParentSiblingHalf-siblingChildAuntUncleNieceNephewGrandparentGrandchildGreats AuntGreat UncleGreat GrandchildMaternal or PaternalMaternalPaternalBothRelative's Cancer TypeBreast cancerOvarianColorectal CancerColon CancerStomach CancerColon AdenomasEndometrialThyroidUterinePancreatic CancerProstateFallopian tubeRenalHematologicalBrain cancerBladderKidneyMelanomaLungCervicalThroatLeukemiaBoneLymphomaOtherAge of Relative when diagnosed with CancerRelationship to youParentSiblingHalf-siblingChildAuntUncleNieceNephewGrandparentGrandchildGreats AuntGreat UncleGreat GrandchildMaternal or PaternalMaternalPaternalBothRelative's Cancer TypeBreast cancerOvarianColorectal CancerColon CancerStomach CancerColon AdenomasEndometrialThyroidUterinePancreatic CancerProstateFallopian tubeRenalHematologicalBrain cancerBladderKidneyMelanomaLungCervicalThroatLeukemiaBoneLymphomaOtherAge of Relative when diagnosed with CancerRelationship to youParentSiblingHalf-siblingChildAuntUncleNieceNephewGrandparentGrandchildGreats AuntGreat UncleGreat GrandchildMaternal or PaternalMaternalPaternalBothRelative's Cancer TypeBreast cancerOvarianColorectal CancerColon CancerStomach CancerColon AdenomasEndometrialThyroidUterinePancreatic CancerProstateFallopian tubeRenalHematologicalBrain cancerBladderKidneyMelanomaLungCervicalThroatLeukemiaBoneLymphomaOtherAge of Relative when diagnosed with CancerRelationship to youParentSiblingHalf-siblingChildAuntUncleNieceNephewGrandparentGrandchildGreats AuntGreat UncleGreat GrandchildMaternal or PaternalMaternalPaternalBothRelative's Cancer TypeBreast cancerOvarianColorectal CancerColon CancerStomach CancerColon AdenomasEndometrialThyroidUterinePancreatic CancerProstateFallopian tubeRenalHematologicalBrain cancerBladderKidneyMelanomaLungCervicalThroatLeukemiaBoneLymphomaOtherAge of Relative when diagnosed with CancerRelationship to youParentSiblingHalf-siblingChildAuntUncleNieceNephewGrandparentGrandchildGreats AuntGreat UncleGreat GrandchildMaternal or PaternalMaternalPaternalBothRelative's Cancer TypeBreast cancerOvarianColorectal CancerColon CancerStomach CancerColon AdenomasEndometrialThyroidUterinePancreatic CancerProstateFallopian tubeRenalHematologicalBrain cancerBladderKidneyMelanomaLungCervicalThroatLeukemiaBoneLymphomaOtherAge of Relative when diagnosed with CancerPlease describe your family cancer history.*If you know of any information regarding the presence of cancer in your family history, please describe it here.* Create a username for your account*Create a password*