Survivors New Member Profile Form

ANGELS SURVIVING CANCER, INC.

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.?

Today's Date:

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:

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

Emergency Contact Relationship

Are you on Facebook

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?

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?

Other

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

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:

Date

Age at diagnosis:

Which breast

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:

When:

Date

Where are you receiving Chemotherapy?

Type of Chemotherapy:

Results/Outcome:

Radiation Therapy

When:

Date

Where are you receiving radiation?

Results/Outcome:

Surgery Options:

Date of Surgery

Date

Where are you receiving surgery?

Results/Outcome

Do you wear prosthetics?

Are you considering reconstruction?

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 $55.00 ($35.00 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.