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Section 1: Contact Information |
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First Name: |
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Last Name: |
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Address: |
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City: |
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State/Province: |
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Zip Code: |
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Country: |
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Phone Number: |
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E-mail Address: |
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Section 2: Cancer Information |
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Type Of Cancer: |
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If Lung Cancer: |
Small
Cell Non
Small Cell Unknown |
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Stage of Cancer: (please check the one that applies.) |
Stage
I
Stage
II
Stage
III Stage
IV
Unknown |
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If Stage IV, to where has the cancer spread? (Please check all that apply.) |
Brain
Bone
Marrow
Lungs
Liver
Lymph
Nodes
Other
(Please describe below.)
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When was the cancer first diagnosed? |
Month
Year |
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Past and current chemotherapy treatments (Please describe below.) |
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Past Treatments? (Please check all that apply.) |
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Radiation (Enter exact site of the body where delivered.) |
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Surgery |
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Other (please describe below.) |
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Current Treatments? (Please check all that apply.) |
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Radiation (Enter exact site of the body where delivered.)
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Surgery |
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Other (please describe below.) |
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When was your last cancer treatment? |
Month
Year |
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Are you currently in treatment? |
Yes
No |
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Has your cancer progressed or responded to the latest treatment? |
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Section 3: Additional Patient Information |
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Name of person with cancer: |
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Age of person with cancer: |
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Gender of person with cancer: |
M
F |
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Will patient travel for treatment? |
50
to 100 Miles
100
to 250 Miles
Anywhere
in the USA
Anywhere
in the world |
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What cancer center has patient been seen at? |
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What studies, if any, have been offered to patient? |
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Additional Comments |
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E-mail Address or Fax Number for Trial Information |
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