South Africa and United Kingdom
082 GENETIC - 082 4363842 - International: +27824363842
BSc, BSc (Med)(Hons), MSc (Med) Genetic Counselling, PhD (Med) Human Genetics
THE SCREENING IS FREE WHEN COMBINED WITH A GENETIC COUNSELLING APPOINTMENT
SERVICES MAY BE COVERED BY YOUR MEDICAL AID
An administration fee of R 75.00, charged for this service, will be credited to you in full should you make a subsequent booking for a genetic counselling session
The fee is levied for the expert analysis of your cancer risk profile and the provision of your personalised cancer risk report.
Your pdf report will be sent to you within 7 working days for your personal review, after which time you may book a genetic counselling session for further personal assessment and genetic evaluation of your cancer risk report
By completing and submitting the cancer risk profile form below, you consent to your personal data which you provide, to be collected, processed and retained in our database, exclusively for the purpose of providing this service to you. We will never share your personal information for any purposes other than determining your cancer risk profile.
COMPLETE THE FORM WITH AS MUCH INFORMATION AS YOU HAVE AVAILABLE
THE MORE INFORMATION YOU PROVIDE THE MORE PRECISE YOUR RISK REPORT
You have completed the initial basic personal information form and the information you provided will be saved on your cancer risk profile
The next part of the questionaire will take a bit of time to complete - we suggest that you set aside no less than 30 minutes to complete the remaining part of the questionaire as you may need to think about family member details, birth dates, dates of deceased family members, and medical history.
If you are in doubt about dates relating to family members you may provide estimated dates as close as possible to your best estimation. An estimated date is not completely ideal, but it is better than no date.
You will be taken through a 12 step process to provide information required
to calculate your own personal cancer risk profile
The information collection process will collect data about some relevant lifestyle factors that have an influence on your personal cancer risk, in addition to your family history and your medical health
While it is possible to click through the YELLOW TABS above, we recommend that you complete one section at a time, starting with "1. LIFESTYLE" and click on the NEXT button at the bottom of each section to advance to the next section,
until the process is completed in sequence.
1. LIFESTYLE
YOUR ALCOHOL CONSUMPTION
WHY DO WE ASK FOR THIS INFORMATION ?
The consumption of alcohol plays a role in the development of cancers and our assessment of your personal cancer risk score therfore takes this into account. It is thus important to provide and apply this information to achieve an accurate personal risk analysis
Please complete the following fields accurately, according to your best asessment of your alcoholic drink consumption.
Please note that the questionaire distinguishes between different types of alcoholic beverages.
PLEASE NOTE THAT WE TREAT ALL YOUR INFORMATION WITH CARE AND PRIVACY
2. WOMEN'S HEALTH
YOUR MENSTRUATION
3. CHILDREN
FAMILY HISTORY (YOUR CHILDREN)
This section of the questionaire will collect information about your biological children.
For the purpose of this process only indicate your birth children born to you
ADD ONE CHILD AT A TIME
Click the "Add Child" button immediately below to add the above child and then add additional children by scrolling up and adding the next child
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Click "Next" to proceed when you have added all children.
4. SIBLINGS
YOUR SISTERS & BROTHERS
FAMILY HISTORY (YOUR SIBLINGS)
This section of the questionaire will collect information about your siblings
viz. Your biological brothers and sisters only
viz. Siblings by blood only
Click the "Add Sibling" button immediately below to add the above sibling and then add additional siblings by scrolling up and adding the next sibling
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Click "Next" to proceed when you have added all siblings.
5. PARENTS
FAMILY HISTORY (YOUR PARENTS)
This section of the questionaire will collect information about your parents
NOTE: Your biological (birth) parents only
NOTE: your blood (birth) parents only
6. MATERNAL AUNTS
"YOUR MOTHERS SISTERS"
FAMILY HISTORY (MATERNAL AUNTS)
This section of the questionaire will collect information about your biological maternal aunts
NOTE: Your maternal aunts are the blood sisters of your mother
Click the "Add Aunt" button immediately below to add the above aunt and then add additional aunts by scrolling up and adding the next aunt
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Click "Next" to proceed when you have added all aunts
7. MATERNAL UNCLES
"YOUR MOTHERS BROTHERS"
FAMILY HISTORY (MATERNAL UNCLES)
This section of the questionaire will collect information about your biological maternal uncles
NOTE: Your maternal uncles are the blood brothers of your mother
Click the "Add Uncle" button immediately below to add the above uncle and then add additional uncles by scrolling up and adding the next uncle
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Click "Next" to proceed when you have added all uncles
8. MATERNAL GRANDPARENTS
"YOUR MOTHERS PARENTS"
FAMILY HISTORY
(YOUR MATERNAL GRANDPARENTS)
This section of the questionaire will collect information about your maternal grandparents
NOTE:
Maternal grandparents are the biological (birth) parents of your mother
9. PATERNAL AUNTS
"YOUR FATHERS SISTERS"
FAMILY HISTORY (PATERNAL AUNTS)
This section of the questionaire will collect information about your biological paternal aunts
NOTE: Your paternal aunts are the blood sisters of your paternal father
"YOUR FATHERS SISTERS"
Click the "Add Aunt" button immediately below to add the above aunt and then add additional aunts by scrolling up and adding the next aunt
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Click "Next" to proceed when you have added all aunts
10. PATERNAL UNCLES
"YOUR FATHERS BROTHERS"
FAMILY HISTORY (PATERNAL UNCLES)
This section of the questionaire will collect information about your biological paternal uncles
NOTE: Your paternal uncles are the blood brothers of your biological father
"YOUR FATHERS BROTHERS"
Click the "Add Uncle" button immediately below to add the above uncle and then add additional uncles by scrolling up and adding the next uncle
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Age, gender
Click "Next" to proceed when you have added all uncles
11. PATERNAL GRANDPARENTS
"YOUR FATHERS PARENTS"
FAMILY HISTORY
(YOUR PATERNAL GRANDPARENTS)
This section of the questionaire will collect information about your paternal grandparents
NOTE:
Paternal grandparents are the biological (birth) parents of your father
"YOUR FATHERS PARENTS"
YOUR MEDICAL HISTORY
This section of the questionaire will collect medical information related to your breasts and your ovaries
Thank You
You have completed the questionaire. Please click the submit button below to finish
We will commence with the determination of your cancer risk profile score immediately after receiving payment of the required adminsitration fee of R 75.00.
Our accounts department will send you an invoice for payment via email, payable on receipt via EFT or online.
Your report will be issued to you within 7 working days (providing payment has been made), after which time you may schedule an appointment online for a genetic counselling consultation to obtain further personal assessment and genetic evaluation of your cancer risk report
Please click on the SUBMIT button below to go to the appointment calendar should you wish to make an appointment in advance.
IMPORTANT : When making a cancer risk counselling booking online, please choose an appointment date that is at least 14 days after the date you completed the questionaire - to provide enough time for your cancer risk profile to be created and analysed.