Lung Cancer Supplemental Survey

1
Please verify that you are human* This field is required.
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.Please be sure to enter the same email affiliated with your Consuli member account.
example@example.com
4
What is your current address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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5
Mobile Phone Number* This field is required.
Please enter a valid phone number.
6
Please indicate your sex assigned at birth (We recognize and respect the spectrum of gender identities and are asking this sex—distinct from gender—for medical reasons).* This field is required.
Female
Male
7
Please indicate your ethnicity (select all that apply).* This field is required.
African American
Asian / Pacific Islander
Caucasian
Hispanic / Latino
Native American
Other
8
Birthdate* This field is required.
Date
Year
Month
Day
9
Are you currently diagnosed with active non-small cell lung cancer (Adenocarcinoma or Squamous Cell only)?* This field is required.
YESNO
10
Are you able to provide evidence of associated tissue biomarker data (EFGR and MET mutations) from your medical records?* This field is required.
YESNO
11
Are you currently pregnant or breastfeeding?* This field is required.
Yes
No
Not Applicable
12
Are you currently enrolled in a clinical trial?* This field is required.
YESNO
13
Have you taken an investigational drug in the past 30 days?* This field is required.
YESNO
14
Do you have a history of past infection with HIV, Hepatitis, or other infectious diseases?* This field is required.
YESNO
15
Have you experienced excess blood loss, defined as 250mL in the last month or 500mL in the previous two months?* This field is required.
YESNO
16
How did you hear about this?* This field is required.
Consuli
HLTH Conference
Samsung Developer Conference
Other
17
What platform did you hear about this on?* This field is required.
Clubhouse
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18
Did you hear about us from a Patient Advocate? If so, please provide their name.
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