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Lymphoma Support Network Questionaire

Questions with an * must be completed in order to process the form. The information you provide will be sent to LRF via e-mail. This is not a secured server. Some Browsers (such as AOL) are not capable of sending forms via e-mail. If you are using such a browser, or prefer to register by mail or fax, please print and return the form to our Los Angeles office. The mailing address and fax number are listed at the bottom of the questionnaire. If you experience any difficulties, or have any questions please do not hesitate to contact Izumi Nakano, LSN Coordinator, at (800) 500-9976 or by e-mail to: support@lymphoma.org.

1. First Name: 
2. Last Name: 
3. Street Address 
4. St. Address 2 
5. City: 
6. State: 
7. Zip Code: 
8. Home Phone: 
9. Other Phone: Work
  Cell
10: Fax: 
11. E-mail: 
12. Indicate your relationship to lymphoma: Patient
 Caregiver
13. Best place and time to reach you:  Home
 Work
 AM
 PM
14. Birth Year (e.g.: 1949)  
15. Gender: Male
 Female
16. Domestic Status: Single
 Married
 Separated
 Divorced
 Widowed
 Other
(Specify) 
PATIENT MEDICAL HISTORY:
17. Patient's Gender: Male
 Female
18. Patient's Birth Year (e.g.: 1949):  
19. Date of Diagnosis
 Month   
 Day       
 Year      
20. Doctor(s): 
22. If Hodgkin's lymphoma, check which stage: I
 II
 III
 IV
23. If Hodgkin's lymphoma, check which specific subtype: Nodular Sclerosis
 Mixed Cellularity
 Lymphocyte Depleted
 Lymphocyte Predominant
24. If non-Hodgkin's lymphoma, check which stage: I
 II
 III
 IV
25. If non-Hodgkin's lymphoma, check which grade: Low (indolent)
 Intermediate(aggressive)
 High (highly aggressive)
26. If non-Hodgkin's lymphoma, check which cell type: B Cell
 T Cell
27. If non-Hodgkin's lymphoma, type in specific diagnosis (For example - Follicular, MALT, CTCL, Small cell cleaved, etc.):
(Max Response 3000 char.)
28. Current Health Status:  Newly Diagnosed
 Watch and Wait
 Relapsed
 In Treatment
 Remission
 Cured
TREATMENT HISTORY:
29. Chemotherapy (please specify regimen):
(Max Response 3000 char.)
30. Radiation:
(Max Response 3000 char.)
31. Stem Cell or Bone Marrow Transplant:
(Max Response 3000 char.)
32. Biological Therapies (e.g. Interferon, Rituxan):
(Max Response 3000 char.)
33. Clinical Trial (please specify which one):
(Max Response 3000 char.)
34. Other (alternative or complementary therapies):
(Max Response 3000 char.)
LIFESTYLE:
35. Occupation: 
36. Hobbies/Interests: 
37. MATCHING PREFERENCES Please select: I would like to be a buddy and give support
 I would like to be a buddy and receive support
38. What is your current need for a buddy? Uncertain
 My intent is to establish a mutual on-going friendship.
 My intent is to hear from my buddy's experiences with a particular treatment.
Matching Criteria:Please rank the following criteria in order of importance, 1-5, 1=most important and 5=least important.
39. Age of Your Buddy 
40. Gender of Your Buddy 
41. Diagnosis 
42. Geographic Location 
43. Treatment 
44. Preferred Method of Communication (please check all that apply): Telephone
 E-mail
 Letter writing
45. Languages Spoken (other than English): 
46. Additional Information, Comments or Questions:
(Max Response 3000 char.)
47. Authorization:
By submitting this form, I hereby authorize LRF to disclose all provided information to any party they so choose for the sole purpose of the Lymphoma Support Network Program. Please type in your initials if you agree to these terms:
 
Date Permission Given:
 Month  
 Day      
 Year    

Once you submit this form, it will be sent to LRF via e-mail. The Coordinator will try to contact you within the next few days.