Si Paradigm

Personal Information
History of Genetic Mutations
Personal and Family History

1) Date of birth?

Please choose date of birth

You are Under Age(Age limit is >=18)

2) Gender at birth?

Please choose answer

Male Female

3) Are you Adopted?

Please choose answer

Yes No

4) What is your ethnicity? Select all that apply

Please choose answer

Caucasian African-American Hispanic Asian Native American Ashkenazi J (Central and Eastern European) I don’t know Decline to answer Other

The Ethnicity you've entered already exists in the provided options.

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5) Have you or any of your relatives had genetic testing previously?

Please select Yes or No

Yes No

5.1) Who

Please choose AlphaNumeric. Character Count should not be greater than 100

5.2) Which gene(s) is positive?

Please choose answer

BRCA1 BRCA2 APC ATM AXIN2 BAP1 BARD1 BMPR1A BRIP1 CDH1 CDK4 CDKN2A CHEK2 EPCAM HOXB13 KIT MEN1 MITF MLH1 MRE11A MSH2 MSH3 MSH6 MUTYH NBN NF1 NTHL1 PALB2 PDGFRA PMS2 POLD1 POLE PTEN RAD50 RAD51C RAD51D RET SDHA SDHB SDHC SDHD SMAD4 STK11 TP53 VHL I don't know other

Please write here!

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If No, please continue

6.1) Have you ever been diagnosed with cancer?

6.1.1) What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

6.1.2) Age at Diagnosis?

Please choose answer

6.2) Do you have another cancer?

6.2.1) What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

6.2.2) Youngest Age at Diagnosis?

Please choose answer

7) Has any of your relatives diagnosed with cancer?

7.1) Who?

First-degree

Parents

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Siblings

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Children

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Paternal Second-degree

Grandparents (2-2)

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Aunts

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Uncles

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Nieces

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Nephews

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Grand children

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Half-siblings

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Maternal Second-degree

Grandparents (2-2)

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Aunts

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Uncles

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Nieces

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Nephews

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Grand children

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Half-siblings

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Paternal Third-degree

Great Grandparents (4-4)

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Great Aunts

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Great Uncles

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

First cousins

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Half Aunts

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Half Uncles

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Maternal Third-degree

Great Grandparents (4-4)

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Great Aunts

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Great Uncles

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

First cousins

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Half Aunts

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

Half Uncles

What type of cancer?

Please choose answer

The cancer type you've entered already exists in the provided options.

Youngest Age at Diagnosis?

Please choose answer

8) Do you have any colon polyps?

Please choose answer

Yes No I haven’t had colonoscopy yet

(Please provide a copy of pathology report)

(Optional)

Please provide a copy of pathology report

File size should not be greater then 20 MB

PDF, Doc/Docx, JPG & PNG files are acceptable only

8.1) What Type

Please choose Polyps Type

8.2) How Many?

Please select value

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Personal Information

Date of Birth?

Gender at Birth?

Are you adopted?

What is your ethnicity?

Personal and Family History

Have you or any of your relative diagnosed had genetic testing previously?

Who?

Which gene(s)?

History of Genetic Mutations

Have you ever been diagnosed with cancer?

What type of cancer?

Youngest Age at Diagnosis?

Do you have another cancer?

What type of cancer?

Youngest Age at Diagnosis?

Has any of your relatives diagnosed with cancer?

First-degree

Parents

Siblings

Children

Paternal second-degree

Grandparents

Aunts

Uncles

Nieces

Nephews

Grand Children

Half-Siblings

Maternal second-degree

Grandparents(2-2)

Aunts

Uncles

Nieces

Nephews

Grand Children

Half-Siblings

Paternal third-degree

Great Grandparents(4-4)

Great Aunts

Great Uncles

First Cousins

Half Aunts

Half Uncles

Maternal third-degree

Great Grandparents(4-4)

Great Aunts

Great Uncles

First Cousins

Half Aunts

Half Uncles

Do you have any Colon Polyps

What type?

How many?

If you want to view or download pathology report, click on download

Download

If you want to view or download pathology report, click on download

Download

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Results

Are you a Medicare patient?

Yes No

You are a candidate for Hereditary Cancer Testing.

Based on the personal and family history you provided, you are a candidate for hereditary cancer testing. Most insurance companies will cover the expenses of the testing. If not, we will contact you prior to testing. Please check with the billing staff at your physician’s office if pre-authorization is needed.

You are not at risk of Hereditary Cancer

Based on the personal and family history you provided and according to the current national medical society guidelines, you are not at increased risk - compared to the general population – of developing hereditary cancer. However, this does not mean that you have zero risk. If you like to be tested, it will be a personal choice and not because of medical necessity. Your insurance company will not cover the testing. Therefore, siParadigm offers you testing using microarray platform at an out of pocket expense of $100.

Do you agree to testing?

Yes No

You are a Candidate for Hereditary Cancer Testing (Please Read the Disclaimer)

Based on the personal and family history you provided, you are a candidate for hereditary cancer testing. However Medicare will not cover the expenses for the testing because you only have family and not personal history of cancer. Therefore, siParadigm offers you testing using microarray platform at an out of pocket expense of $100.

Do you agree to testing?

Yes No

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