Patient Application-Online

PATIENT APPLICANT INFORMATION

First Name:

Last Name:

Date of Birth

Age:

Cell Phone:

Home Phone:

Current address:

City:

State

Zip:

Email address:

Preferred contact method:

Cell Phone

Home Phone

Email

For phone, preferred time?

Primary language:

Other language(s):

Race and/or ethnicity if you would like to share:

Religious Affiliation:

Congregation:

Are you currently employed?

Yes

No

Place of employment

Position:

YOUR CANCER JOURNEY

Type of cancer:

Date Diagnosed

Cancer stage:

Has your cancer metastasized?

Yes

No

If yes, location:

Name of Hospital/Medical Center where you are being treated:

City

State

Treating Doctor:

Contact Number

Current treatments: (Choose all that apply):

List chemotherapy drugs:

Type of surgery:

Name of clinical trial:

Name of alternative treatment:

Other, explain:

Please let us know of any therapies and practices you are interested in using or learning more about to manage the physical and emotional symptoms of gynecologic cancer: (Choose all that apply):

Therapies

PEER TO PEER COMMUNICATION

Do you feel comfortable being matched with a mentor who has a different gynecologic cancer type than yours?

Yes

No

Do you feel comfortable being matched with a mentor who has a different treatment history than yours?

Yes

No

How would you prefer to communicate with your mentor? (Choose all that apply):

If you selected “In person”, what is the maximum miles you would travel?

How often do you think you would like to communicate with your mentor: (Choose all that apply)

What are your hobbies, interests, and favorite ways to relax?

Mentor Characteristics – Rate the importance of your match with your mentor: 1 star = least important, 5 stars = most important

Age

Diagnosis

Treatment

Race

Religion

Marital status

Family

Location

Hobbies

Are there any other characteristics that are important to you in being matched with a mentor?

Yes

No

If yes, please explain:

Is there anything else about your journey that you would like to share? (e.g. genetic testing, family dynamics, special circumstances):

For questions, please contact Ayushe Sharma, the UAB site’s Women to Women Program Coordinator, at 205-934-5761 or sharma87@uab.edu.

Woman to Woman Peer Support Program