Pink-4-Ever :: Survivor Questionnaire

Name
Address
City
State
Zip Code
County
Phone Number
Email Address
How long have you lived at your current residence
Where were you living when you were diagnosed?
Race & Ethnicity
Date of Birth
Marital Status
Do you have children?
If yes, what are their ages and gender
At time of diagnosis, did you have medical insurance?
Age at diagnosis
Year of diagnosis
Type and stage of breast cancer
Do you have a Family history of breast cancer?
Did you have genetic testing?
If yes, what was the results of the test?
How did you discover your breast cancer?
Explain your treatment (surgery, radiation, chemotherapy, reconstruction)
Tell us a specific memory thoughout your journey that stands out
Any recurrence?
Did you particpate in a support group?
What is your involvement with Pink-4-Ever, Inc
Which of the following media are you comfortable participating with upon your permission?	Newspaper/Magazine TV Interview P4E Website P4E Pink Newsletter Radio PSA
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