Survivors New Member Profile Form

New Members Profile Form

(Breast Cancer Survivors)

The sole purpose of this form is to collect data specifically relating to members. This information will be included in a database which will enable us to evaluate and determine which factors, such as family history, early detection practices, treatment variances, types and stages of diagnosis, socio-economic factors, and treatment facilities, play a pivotal role in breast cancer development, diagnosis, treatment, survivorship, and quality of life. All information provided this form will be kept confidential and access to this information will be strictly regulated and monitored. Your data will be entered into the database under a membership number; your name will not be included.
Would you like to become a member of ASC, Inc.?*

YesNo
Today's Date:*

MonthDayYear
Date
Name:

First NameLast Name
Birth Date*

MonthDayYear
Age*
Phone Number:

Area CodePhone Number
E-mail Address:*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race/Ethnicity: *
Your Education:
Currently Employed? If yes, name and address of current employer
Marital Status:

SingleMarriedDivorcedWidow
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Relationship*
Are you on Facebook*

YesNo
HISTORY

Below are a few questions about your history. Please take your time and answer each question to the best of your ability
Do you have a family history of breast cancer?*
If yes, who?

MotherPaternal GrandmotherMaternal GrandmotherAuntSisterOther
Do you have children?*
If yes, age at first pregnancy
Have you ever had a previous breast biopsy?
If yes, how many?
How was the mass/lump detected?

SelfMammogramClinician/PhysicianOther
Before diagnosis, were you doing any of the following? Select all that apply:

performing monthly breast self-exams (BSE)?getting annual clinical breast exams (CBE)?having annual mammograms?None of the above
Diagnosis

Below are a few questions about your diagnosis. Please take your time and answer each question to the best of your ability
Date of diagnosis:

MonthDayYear
Date
Age at diagnosis:*
Which breast

LeftRightBoth
Stage & Type of Cancer?
Do you have you pathology report?*
Treatment

Below are a few questions about your past/present treatment. Please take your time and answer each question to the best of your ability
Do you currently have insurance?*
Are you currently in treatment?*
Chemotherapy Therapy:

YesNo
When:

MonthDayYear
Date
Where are you receiving Chemotherapy?
Type of Chemotherapy:
Results/Outcome:
Radiation Therapy*

YesNo
When:

MonthDayYear
Date
Where are you receiving radiation?
Results/Outcome:
Surgery Options:

LumpectomyModified radical mastectomyBilateral mastectomyRadical mastectomyOther
Date of Surgery

MonthDayYear
Date
Where are you receiving surgery?
Results/Outcome
Do you wear prosthetics?
Are you considering reconstruction?*

YesNo
Any Recurrence(s)?*
Please explain how Angels can help you. Are there any resources you need at this time?
Name of person who referred you:

First NameLast Name
The Annual Dues for membership is $50.00 ($30.00 seniors 70 yrs. older) Please submit your payment below or by clicking You can also visit our site at www.angelssurvivingcancer.org If you have any questions or concerns, Please contact us directly at info@angelssurvivingcancer.org and we will be more than happy to assist you.
If you are in need of a free wig, Please contact Beauty Beyond Breast Cancer- Venita Graves at 832-372-4247. Please let her know Angel's referred you. (By appointment only)

If you currently do not have insurance or medicare, please contact Tricia Garmond with MD Anderson at 713-563-2013
Anything Below this Line is For Office Use Only:
Full Name of Angel who took the Call:
Is Follow-up Needed
Follow-up Date & Time:
Should be Empty: