| Risk Factor | Breast Cancer at Age ≤50 y | Ovarian Cancer at Any Age |
|---|---|---|
| Yourself | ||
| Mother | ||
| Sister | ||
| Daughter | ||
| Mother’s side | ||
| Grandmother | ||
| Aunt | ||
| Father’s side | ||
| Grandmother | ||
| Aunt | ||
| ≥2 cases of breast cancer after age 50 y on the same side of the family | ||
| Male breast cancer at any age in any relative | ||
| Jewish ancestry | ||
A patient completes the checklist if she has a family history of breast or ovarian cancer and receives a referral if she checks ≥2 items.