Contact Information:
Name
*
First Name
Last Name
E-mail
*
example@example.com
Street Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
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Delaware
District of Columbia
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Michigan
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Ohio
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South Dakota
Tennessee
Texas
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Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Cell Phone
*
Format: (000) 000-0000.
Please reach me by:
*
Phone
Email
Text Message
Breast Cancer Information
Date of Birth
*
/
Month
/
Day
Year
Date of Diagnosis
*
/
Month
/
Day
Year
Age(s) at Diagnosis
*
(if applicable)
Age of Children at Diagnosis
(if applicable)
Description of Breast Cancer Diagnosis
Stage (please check all that apply):
*
Previvor
0/DCIS or LCIS
1
2A
2B
3A
3B
3C
4 Metastatic
If your cancer is metastatic, please indicate affected areas
*
Hormonal Receptor Description (please check all that apply):
*
ER+
ER-
PR+
PR-
HER2+
HER2-
Genetic Mutation:
*
Yes
No
If yes (please check all that apply):
*
BRCA1
BRCA2
Other (please specify)
Menopause Stage at Diagnosis:
*
Premenopausal
Postmenopausal
Multiple Diagnoses:
*
Spread to Lymph Nodes
Lymphedema
Breast Cancer Recurrence
None
Other
Breast Cancer Recurrence:
Local
Distant
Other
Location of Distant Recurrence:
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Surgery Information:
*
Lumpectomy
Single Mastectomy
Double Mastectomy
Lymphadenectomy
Prophylactic Surgery
None
Other
Reconstruction:
*
Yes
No
Type of Reconstruction:
*
Implants
Flap
Hybrid
Nipple
Other
Treatment Information:
*
Chemotherapy
Cold Cap Therapy
Hormonal Therapy/Aromatase Inhibitors
Immunotherapy
Radiation
Other
Please tell us which parameters are most important to you for pairing purposes:
*
Diagnosis
Genetics
Surgery
Survivorship
Age
Small Children
Treatment
Other
Are you fluent in other languages? If so, which ones?
Please provide any other information about yourself that you think may be helpful in pairing you with a new warrior:
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