• Participant Information Form (Please Print Clearly) We do not share your medical information with any third party providers without your permission.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birth Year
  • Birth Year
  • Ethnicity (optional)
  • Ethnicity (optional)
  • Approx date of initial diagnosis (MM/YYYY)
  • Approx date of initial diagnosis (MM/YYYY)
  • HER2 Test DBorderline ONegative IPositive Clunsure
  • What is your current breast cancer status?
  • What is your current breast cancer status?
  • Are you CURRENTLY receiving Radiation?
  • Are you CURRENTLY on hormonal treatment such as Tamoxifen or an aromatase inhibitor? ONo DYes
  • Approx. date of surgery (MM/YYYY)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Lumpectomy
  • Sentinel Node Biopsy (SNB)
  • side
  • Reconstruction?
  • Reconstruction?
  • Do
  • Add any additional explanations re: your stage, status, or treatment
  • Is there any swelling in your arm, chest, or abdomen? DNo DYes (please explain)
  • Do you have any other medical conditions we should know about? ONo DYes (please explain)
  • Do you use a mobility device for assistance?
  • Do you use a mobility device for assistance?
  • Do you have hearing or vision impairments?
  • Do you have any dietary restrictions/allergies?
  • Do you plan to smoke or vape tobacco or medical marijuana (legally with card) at the retreat?
  •  
  • Should be Empty:
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