Philo Project Inquiry

Philo Project Inquiry

This survey is not designed to diagnose or treat cancer or any other condition. The information provided is intended to assist in selecting/prioritizing applicants to receive a full-body MRI through Vigilant Torch and Prenuvo. If you are having any troubling symptoms, you should discuss them with your medical provider or physician.
Eligibility

There is currently NO funding to have another Philo Cohort at this time. This application is intended to assist us in creating a demand signal for anyone who is still interested in the MRI and helps us communicate the need for donors. When we do secure funding for any additional cohorts, to be eligible for Vigilant Torch to pay for your full-body MRI, you must be a Vigilant Torch Member or you must be currently assigned to one of our supported Special Operations units. If you have questions about your membership or your eligibility, please contact membership@vigilant-torch.org or Brian Gellman at briang@vigilant-torch.org
Funding

This application is not a guarantee that you will receive treatment funded by Vigilant Torch. Medical professionals will review the information that you provide and will determine your level of risk. Vigilant Torch will fund scans for those at the highest risk subject to the availability of funds.
Cohorts

There is no window for this application, it is a rolling application for us to understand demand signal on who is interested in the MRI, to assist us in campaigning for additional funding for the Philo Porject.
Additional Information:

For additional information on the Philo Project, please go to our website at www.vigilant-torch.org
Name*

First NameLast Name
Email*
example@example.com
Are you enrolled in NEXUS? If so, please contact the NEXUS Director for a different application.

YesNo
Which best describes your status?*
If you have questions about your eligibility, please email membership@vigilant-torch.org
Phone Number*
Please enter a valid phone number.
How old are you? *
How tall are you? (Inches)*
How much do you weigh? (Pounds)*
What is your biological sex?*

MaleFemale
Have you ever been diagnosed with cancer?*

YesNo
Can you tell us more about what kind of cancer, what treatments have you had, and what is the current status?

Do you have a first- or second- degree family history of any of the following cancers? (this includes parents, siblings, aunts/uncles, cousins)

	Paternal	Maternal
Breast Cancer
Cervical Cancer
Lung Cancer
Colorectal Cancer
Other

If you selected other, what types of cancer(s)?
Do you have a primary care provider?*

Yes, I have seen them within the last yearYes, but I have not seen them in over a yearNo
What is your current military status?*

Active DutyActive Guard/ ReserveGuard/ ReserveVeteran < 20 Years of ServiceRetired >20 Years of ServiceMedically Retired
Which branch of service were you most recently affiliated with?*

ArmyMarine CorpsAir ForceSpace ForceNavyCoast Guard
Which of the following describes your highest rank obtained? *
16. Which of the following military occupations were you a part of?*

Aviation PilotAviation CrewSOF AviationSEALSWCCSpecial ForcesRangerPararescueDAGREJTAC/TACPMarine ReconnaissanceMarine RaiderMedicalInfantryPsyop/ Civil AffairsIntelligenceOrdinance/ AmmoElectronics/SignalsOGASOF Enabler
Which of the following locations have you deployed to?*

AfganistanIraqKuwaitNigerDijiboutiGuamGermanyJapanQatarSyriaUzbekistanAfricaNoneOut West (Training Area)Other
History of cigarette use?*

Current UserFormer UserNever
If you have used cigarettes, if you add up all of the years when you regularly smoked cigarettes, have you smoked for 20 years of more of your life?*

YesNo
At any time in your life, did you regularly smoke one or more packs of cigarettes per day?*

YesNo
Are you up to date on your recommended mammogram?*

YesNoI don't know
Are you up to date on your recommended cervical cancer screening?*

YesNoI don't know
Are you up to date on your recommended colorectal cancer screening?*

YesNoI don't know
Are you up to date on your recommended lung cancer screening?*

YesNoI don't know
Date*

MonthDayYear
Date
Signature, By signing below, you acknowledge that this information was submitted willingly, and voluntarily, with truthful knowledge and good intent. In addition, you understand that any information shared with members of the Vigilant Torch Philo Project/ Prenuvo Team are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and you are protected under federal law and national standards that the Vigilant Torch Philo Project/ Prenuvo Team is mandated to protect including sensitive patient health information. You understand the foundation will never disclose any potentially, personal, identifiable information about the veteran without the veterans consent or knowledge.*

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Philo Project Inquiry

Eligibility

Funding

Cohorts

Additional Information: