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Updated 10-28-15 Page 1 of 2
Pre-Conference Workshop:
Cancer Risk Assessment and Genetic
Counseling
November 18, 2015
Location: Fez 1
Time: 9:00 – 13:00
Case Presentation from Your Practice
Your Name: ____________________________________________________
(Please include your name on all documents)
Your Practice Discipline (MD, RN, etc):_______________________________
Your Practice Institution:__________________________________________
Date _____________
Use this form to describe one or more challenging or interesting case from your clinical
experiences to present during the AORTIC pre-conference workshop.
Please respond directly on this form under each numbered prompt below. Questions on the
form will move to accommodate the amount of space needed for each response. Email the
completed from along with scanned copy of the family history pedigree and an *anonymized
copy of relevant patient or family genetic test results (if testing was done) to: Kristyna Hulland
[email protected] NO LATER THAN Saturday, November 14, 2015.
*All personal patient identifying information MUST be blocked or removed from all
documents
1. Case synopsis (pertinent details of the case and the presenting problems):

Updated 10-28-15 Page 2 of 2
2. Draw the family history (pedigree) as a separate document. It can be hand drawn or
electronic format. If hand drawn make sure pedigree is neat with clearly written ages
and notations. Be sure to include icons and a legend. DO NOT include any patient
identifiers (no names or other identifying information). Convert the document to a jpg,
tiff, pdf, or ppt file to send with this completed from by email (see previous page).
3. If genetic testing was performed, please include an copy of the genetic test results.
Remove all patient identifiers before converting the document into a jpg, tiff, pdf, or
ppt file to send along with this completed form by email see previous page).
4. If testing was not performed, please explain the reason here:
5. If there were any challenging psychological, ethical, legal, insurance or familial issues
to discuss related to the case describe briefly:
6. List TWO or more main reasons you are presenting this case:
Tha
Thank you for submitting your case! nk you for submitting your case!