Patient & Provider Forms
Forms for Patients
Some forms are multiple pages; please complete all pages.
Forms for Providers
Women's Genetic Counseling at the Women's Medicine Collaborative offers comprehensive evaluation for individuals and family members at risk of hereditary cancer syndromes.
A genetics evaluation can help an individual determine whether she has inherited an increased risk for cancer. Approximately 5 to 10 percent of all cancers are hereditary.
Women should consider a genetics evaluation if they meet any of the following criteria:
- Personal history of cancer, such as breast or colon cancer, under the age of 50
- Two or more first-degree relatives on the same side of the family who have been diagnosed with cancer
- More than one primary cancer (such as two primary breast cancers, or primary colon cancer and primary stomach cancer)
- More than one type of cancer
- A rare type of cancer
- Triple negative breast cancer before age 60
- A known genetic mutation in a cancer susceptibility gene in the family
- Ashkenazi Jewish descent (Eastern European Jewish)
Led by Chanika Phornphutkul, MD, our team of genetic specialists provide a comprehensive genetics evaluation, which includes:
- Providing a risk assessment based on personal and family history
- Discussing genetic testing options
- Review of cancer screening and management options
- Counseling on hereditary cancer syndromes
For more information or to schedule an appointment, please call us at 401-793-7410.
Chanika Phornphutkul, MD, is the director of human genetics at Rhode Island and its Hasbro Children’s Hospital, and is an associate professor of pediatrics at The Warren Alpert Medical School of Brown University. She provides genetic risk assessment as well as counseling for patients with a family history of genetic disorders. She is board certified in pediatric endocrinology and biochemical genetics.
Phornphutkul received her medical degree from the Chiang Mai University School of Medicine in Thailand, and completed her residency at Mott Children’s Hospital in Ann Arbor, Michigan and Hasbro Children’s Hospital in Providence, Rhode Island. She completed a fellowship at Hasbro Children’s Hospital and the National Institutes of Health in Bethesda, Maryland. Her clinical and research interests focus on biochemical genetics (metabolic disorders), the application of genomic information in clinical medicine and newborn screening.