Chemotherapy Care Kit Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the patient between the ages of 21-40?
*
Yes
No
Patients date of birth
*
-
Month
-
Day
Year
DOB
Is chemotherapy or immunotherapy part of the patients treatment plan?
*
Yes, chemotherapy is part of the treatment plan
No, chemotherapy is not part of the treatment plan
Unsure
Has the patient started chemotherapy or immunotherapy?
*
Yes
No
How many rounds of chemotherapy and/or immunotherapy does the patient have left in the treatment plan?
*
1-5
6-10
11-20
21+ and/or indefinitely
What is the patients ethnicity?
*
American Indian or Alaska Native
Asian
Black of African American
Hispanic or Latino
White
Other
Prefer not to answer
What is the patients employment status?
*
Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Other
Prefer not to answer
Does the patient have dependents?
*
Yes, children
Yes, family members
No
Other
Stage of Diagnosis
*
DCIS/Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Type of Breast Cancer
*
Ductal Carcinoma in Situ (DCIS)
Invasive Ductal Carcinoma (IDC)
Invasive Lobular Carcinoma (ILC)
Lobular Carcinoma in Situ (LCIS)
Subtype of Breast Cancer
*
Hormone Receptor-positive (ER+PR+)
HER2-positive, Hormone Receptor-negative
Triple-negative
Triple-positive (HER2-positive, ER+Pr+)
Inflammatory
Patient Size (for port shirt)
*
X-SMALL
SMALL
MEDIUM
LARGE
X-LARGE
Port Location (for treatment)
*
Left side
Right side
What hospital or healthcare system are you currently receiving treatment through?
*
Below is a list of statements that other people with breast cancer have said are important. Please mark one bubble per line to indicate your response as it applies to the past 7 days.
*
Rows
Not at all
A little bit
Somewhat
Quite a bit
Very much
I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment
My out-of-pocket medical expenses are more than I thought they would be
I worry about the financial problems I will have in the future as a result of my illness or treatment
I feel I have no choice about the amount of money I spend on care
I am frustrated that I cannot work or contribute as much as I usually do
I am satisfied with my current financial situation
I am able to meet my monthly expenses
I feel financially stressed
I am concerned about keeping my job and income, including paid work at home
My cancer or treatment has reduced my satisfaction with my present financial situation
I feel in control of my financial situation
My illness has been a financial hardship to my family and me
To process your application, we require documentation confirming your breast cancer diagnosis. Accepted forms of documentation include: a letter from your physician, relevant medical records, or diagnostic testing results | Note: The documentation must be dated within the past 3 months.
*
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