Sample PIF for Jotform - created by Jotform

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

Location of Retreat

Date

Nickname/Preferred name

Address

Street Address Line 2

City

State

Zip

Day phone

Cell Phone

Email

example@example.com

Emergency

Phone

Relationship

Birth Year

OccupationEmergency: ContactPhone

Birth Year

Ethnicity (optional)Other:

Birth Year

OEnglish

Other

Ethnicity (optional)

Have you received a breast cancer diagnosis? DINo DYesApprox date of initial diagnosis (MM/YYYY)

Approx date of initial diagnosis (MM/YYYY)

If your stage of breast cancer at diagnosis was Stage 0-III, have you had a recurrence of breast cancer? ONo DYes Do you currently have metastatic disease Stage IV? Metastatic means your breast cancer has spread beyond the breast and nearby lymph nodes to other parts of your bodyNoTYesHER2 Test DBorderline ONegative IPositive Clunsure

HER2 Test DBorderline ONegative IPositive Clunsure

If Stage IV (breast cancer has spread beyond breast to other part of body). where has it spread to?

What is your current breast cancer status?

DEvidence of DiseaseUnsureDNo Evidence of Disease (NED)

What is your current breast cancer status?

Are you CURRENTLY on hormonal treatment such as Tamoxifen or an aromatase inhibitor? ONo DYesAre you CURRENTLY receiving Radiation?

Are you CURRENTLY receiving Radiation?

Are you CURRENTLY on Chemotherapy? ONoYesINoYes

Are you CURRENTLY on hormonal treatment such as Tamoxifen or an aromatase inhibitor? ONo DYes

Approx. date of surgery (MM/YYYY)

Date

Lumpectomy

Axillary Lymph Node Dissection (ALND)

Sentinel Node Biopsy (SNB)

Both sides

Sentinel Node Biopsy (SNB)

Reconstruction?side

side

SNB ONoDeftRight sideIBoth sides

Reconstruction?

DNoYesIf yes, type of reconstruction

Reconstruction?

DoExplain any ongoing care issues related to surgery, procedures, etc.

Explain any ongoing care issues related to surgery, procedures, etc.

Do

Add any additional explanations re: your stage, status, or treatmenthave a port? DNo DYes If yes, where is your port located? you

Add any additional explanations re: your stage, status, or treatment

Is there any swelling in your arm, chest, or abdomen? DNo DYes (please explain)Additional surgeries. if any

Additional surgeries. if any

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 have neuropathy (numbness)? ONo OYes If yes, where?

Do you have any other medical conditions we should know about? ONo DYes (please explain)

Are you able to walk one flight of stairs without assistance? DNo DYesDo you have any physical or mobility restrictions: ONo DYes (please explain)

Do you use a mobility device for assistance?

Are you able to walk 1/8 mile without assistance? DNo DYesAre you able to walk on uneven surfaces. such as a rocky path, without assistance? DNo DYes

Do you use a mobility device for assistance?

Do you have hearing or vision impairments?

JNolYes (please explain)

Do you have hearing or vision impairments?

Do you have any dietary restrictions/allergies?

INoDYes (please explain)

DYes (please explain)

]Yes (please explain)

Do you plan to smoke or vape tobacco or medical marijuana (legally with card) at the retreat?

You may have a roommate; do you have any sleeping issues? DNo Yes please explain

Do you plan to smoke or vape tobacco or medical marijuana (legally with card) at the retreat?

DNoIYes, tobaccoYes, marijuana