General Details			* indicates required field
	Names of Patient: (eg peter smith)
	Gender:	Male Female
	Age of Patient:
	Code of Patient:
	Date of Birth: (dd-mm-yyyy)
	Individual Genetic File Number: *
	Family Genetic File Number:
	Clinic or facility for consultation:
	DNA Diagnostics
	Mutational Analysis of proband status: *	Requested Not Requested Completed Incomplete
	Predictive DNA Testing requested:	Yes No Not Applicable
	Patient Type:	Non Polyposis Multiple Polyposis
	If predictive, which gene is involved in family?	MLH1 MSH2 MSH6 PMS2 Other Not Applicable		Family Specific Mutation:
	If predictive, which gene is involved in family?	APC MYH Other Not Applicable		Family Specific Mutation:
	Mutation identified by:	Protein Truncation Testing Deletion Studies Sequencing Chromosome Analysis Other
	Mutation identified by:	Protein Truncation Testing Deletion Studies Sequencing Chromosome Analysis Other
	<Page 1>

	Hereditary Non Polyposis Colorectal Cancer			* indicates required field
	Familial Risk: *
	Amsterdam 1 Family:	Yes No Uncertain
	Amsterdam 2 Family:	Yes No Uncertain
	Amsterdam 2 Family:	No Uncertain
	Bethesda Criteria met for this patient:	Yes No Uncertain
	Clinical parameters determining risk:
	This patient:
	Affected with Colorectal Cancer?	Yes No Uncertain
	Age first Diagnosed?
	Has it been verified?	Yes No Pending
	Diagnoses verified ? (leave unfilled if none)	Pathology	Cancer Register	Death Certificate
	Affected with Colorectal Adenoma?	Yes No Uncertain
	Age first Diagnosed?
	Has it been verified?	Yes No Pending
	Diagnoses verified ? (leave unfilled if none)	Pathology	Cancer Register	Death Certificate
	Affected with other HNPCC cancer?	Yes No Uncertain
	Age first Diagnosed?
	Has it been verified?	Yes No Pending
	Diagnoses verified ? (leave unfilled if none)	Pathology	Cancer Register	Death Certificate
	Affected with other cancer?	Yes No Uncertain
	Age first Diagnosed?
	Has it been verified?	Yes No Pending
	Specify type of Non colorectal cancer :
	Diagnoses verified ? (leave unfilled if none)	Pathology	Cancer Register	Death Certificate
	Likely Lineage:	Paternal Maternal Unsure
	<Page 2>

	Paternal 1st Deg Relatives: *				* indicates required field
	Number Affected with Colorectal Cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with Colorectal Adenoma?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other HNPCC cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Diagnoses verified ? (Leave unfilled if none)	Pathology	Cancer Register	Death Certificate
		Family History	Partially	Completely
	Paternal Other Relatives:
	Number Affected with Colorectal Cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with Colorectal Adenoma?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other HNPCC cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Diagnoses verified ? (Leave unfilled if none)	Pathology	Cancer Register	Death Certificate
		Family History	Partially	Completely

	Maternal 1st Deg Relatives : *
	Number Affected with Colorectal Cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with Colorectal Adenoma?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other HNPCC cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Diagnoses verified ? (Leave unfilled if none)	Pathology	Cancer Register	Death Certificate
		Family History	Partially	Completely
	Maternal Other Relatives:
	Number Affected with Colorectal Cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with Colorectal Adenoma?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other HNPCC cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Number Affected with other cancer?	0 1 2 3 4 5+ Unknown Irrelevant
	Age first Identified?
	Diagnoses verified ? (Leave unfilled if none)	Pathology	Cancer Register	Death Certificate
		Family History	Partially	Completely
	<page 3>

	Tumor Testing				* indicates required field
	MSI status: *
	This patient:	Untested MSI - H MSI - L MSS Unknown
	Any Other Relative(s)?	Yes No
	Relative 1 Type	1st Degree 2nd Degree 3rd Degree Other	Relative 1 Gene	Untested MSI - H MSI - L MSS Unknown	More Relative(s)?	Yes No
	Relative 2 Type	1st Degree 2nd Degree 3rd Degree Other	Relative 2 Gene	Untested MSI - H MSI - L MSS Unknown	More Relative(s)?	Yes No
	Relative 3 Type	1st Degree 2nd Degree 3rd Degree Other	Relative 3 Gene	Untested MSI - H MSI - L MSS Unknown	More Relative(s)?	Yes No
	Relative 4 Type	1st Degree 2nd Degree 3rd Degree Other	Relative 4 Gene	Untested MSI - H MSI - L MSS Unknown	More Relative(s)?	Yes No
	Relative 5 Type	1st Degree 2nd Degree 3rd Degree Other	Relative 5 Gene	Untested MSI - H MSI - L MSS Unknown
	IHC(MMR): *
	This patient:	MLH1 Loss Untested Unknown Yes No Indeterminent	MSH2 Loss Untested Unknown Yes No Indeterminent	MSH6 Loss Untested Unknown Yes No Indeterminent	PMS2 Loss Untested Unknown Yes No Indeterminent
	Any Other Relatives:	Untested Unknown Yes No Indeterminent	Untested Unknown Yes No Indeterminent	Untested Unknown Yes No Indeterminent	Untested Unknown Yes No Indeterminent
	BRAF V600E:
	This patient:	Untested Positive Negative
	<Page 4>

	Mutational Analysis With Respect to Phenotype			* indicates required field
	Mutation Identified? *	Yes No Untested Unclassified Variant
	Which Gene ?	MLH1 MSH2 MSH6 PMS2
	Mutation Specify :
	Segregation of affected with mutation concordant	Yes No Unknown Not Applicable
	Penetrance complete :	High Moderate Low Not Assessable
	Clinician's Assessment of Pathogenicity	Definite Probable Possible Not Pathogentic
	Clinician's comment
	<Page 5>

	Multiple Polyposis:
	Clinical paramaters determing risk
	This Patient:
	Best estimate of number of colorectal adenoma : (leave unfilled if unknown)
	At age?
	Affected with cancer?	Yes No Unknown
	Duodenal Adenomas?	Yes No Unknown
	CHRPEs found?:	Yes No Unknown
	Ostermas:	Yes No Unknown
	Other syndromic features:
	Surgery :
	Colectory and Ileostomy Anastomosis
	Total Proctocolectomy and Brook Ileostomy
	Total Proctocolectomy and Kock Ileostomy
	Restorative Proctocolectomy
	Rectoral Excision
	Whipples'
	Desmoid Excision
	Other
	Relatives:
	Parent Affected with FAP ?	Yes No Unknown	Classic		Attenuated
	Type of Affection ?	FAP Cancer FAP + Cancer
	Paternal/Maternal?	Paternal Maternal
	Sibling(s) Affected with FAP ?