BreastCancerTrials.org History Form: Completed Treatment for

 BreastCancerTrials.org History Form: Completed Treatment for Breast Cancer This form is for patients with DCIS or early stage invasive cancer who are:  On hormone therapy after breast cancer surgery  Or who have completed all therapy for DCIS or early stage invasive cancer ABOUT ME Year of Birth: ____________ Gender: □ Female □ Male Your menopausal status: □ Premenopausal Currently pregnant: □ Yes □ No Currently nursing: □ Yes □ No □ Perimenopausal □ Postmenopausal Why did your menstrual cycle end? □ Natural menopause (absence of monthly menstrual period for 12 months or more □ Removal of both ovaries □ Radiation treatment □ Hormone‐induced menopause □ Chemotherapy Have you ever taken hormone replacement therapy for menopausal symptoms? □ No □ Yes: not currently on □ Yes: currently on Have you had genetic testing for breast cancer? □ Yes BRCA1: Positive Negative BRCA2: Positive Negative □ No Are you currently on a clinical trial? □ Yes □ No MY HEALTH Your general well‐being (for past two weeks) □ I am fully active, I have no complaints or symptoms □ It takes a bit of effort to do my normal activity □ I require occasional assistance, but am able to care for most of my personal needs □ I require a large amount of assistance and frequent medical care □ I am completely disabled and am totally confined to bed or chair Your past & current diagnoses: select all that apply □ Primary cancer other than breast cancer □ Bone □ Brain, spinal cord (central nervous system) □ Cervical carcinoma, invasive □ Cervical carcinoma, in situ □ Colon/rectal □ Hodgkin's disease Intestinal □ Kidney □ Leukemia or abnormal bone marrow cells that may lead to leukemia (myelodysplasia) □ Lung □ Lymphoma □ Ovarian □ Pancreatic □ Prostate □ Skin: basal or squamous cell □ Skin: melanoma □ Thyroid □ Uterine □ Other cancer: ________________ □ AIDS / HIV □ Anemia (severe) or blood □ Severe anemia □ Abnormal bleeding / clotting requiring medication □ Other: _____________________ □ Autoimmune (lupus, scleroderma) □ Scleroderma □ Systemic Lupus Erythematosus (SLE) □ Other: ______________________ □ Breathing or lung □ Blood clot in lung (pulmonary embolism) □ Chronic lung disease (COPD or emphysema) □ Asthma requiring medication □ Other: _______________________ □ Digestive system (stomach, intestine, liver, colon) □ Hepatitis B □ Hepatitis □ Cirrhosis □ Other: _______________________ □ Diabetes (continued) □ Cardiovascular (heart, blood pressure) □ Chest pain (angina) □ Irregular heart beat (arrhythmia) □ Weakness of heart muscle (congestive heart failure) □ Blood clot in leg (Deep Vein Thrombosis / DVT) □ Heart attack Year of most recent heart attack: __________________ □ High blood pressure □ Other: _____________________ □ Kidney, urinary or bladder □ Kidney condition: dialysis □ Kidney condition: medication, no dialysis □ Other: _____________________ □ Nervous system or brain □ Damage to nerves causing numbness / pain / weakness (peripheral neuropathy) □ Blood clot to brain (stroke) □ Other: _____________________ □ Osteoporosis □
Thyroid or other hormonal □ Hyperthyroidism □ Hypothyroidism □ Other: _____________________ □ Vaginal, uterine, or other reproductive organ □ Thickened lining of the uterus (endometrial hyperplasia) □ Endometriosis □ Abnormal vaginal bleeding □ Other: _____________________ □ Any other health condition(s)?: _______________________________________________________ _____________________________________________________________________________________ MY DIAGNOSIS Year of most recent diagnosis: _____________ The questions below pertain to either the right breast or left breast Type of diagnosis □ Ductal Carcinoma In situ (DCIS) □ Ductal carcinoma (invasive or infiltrating) □ Lobular carcinoma (invasive or infiltrating) Stage at diagnosis □ In Situ (DCIS) □ Stage I □ Stage II □ Stage III □ Not Yet Determined Was the cancer described as inflammatory breast cancer? □ No □ Yes □ I’m not sure Tumor's Estrogen Receptor (ER) status (sometimes called "hormone receptor status") □ Positive □ Negative □ Unclear/Indeterminate results □ Not tested □ I’m not sure Tumor's Progesterone Receptor (PR) status □ Positive □ Negative □ Unclear/Indeterminate results □ Not tested □ I’m not sure Tumor's HER2/neu Receptor status □ Positive □ Negative □ Unclear/Indeterminate results □ Not tested □ I’m not sure Tumor size, as determined by surgery □ Less than 2.0cm □ 2.1 ‐ 5.0cm □ Over 5.0cm □ I’m not sure/I haven’t had surgery yet Was this your first diagnosis of breast cancer? □ Yes □ No Has cancer been found in either your sentinel lymph node or other nodes of your armpit (also called axillary lymph nodes)? □ Yes □ No/not tested □ I’m not sure Select all areas where cancer was found? □ Lymph nodes above collarbone (supraclavicular nodes) □ Lymph nodes below collarbone (infraclavicular nodes) Chest wall □ Other: ____________________________ Have you ever been diagnosed with lymphedema? □ No □ Yes □ I’m not sure Additional information: _____________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ MY TREATMENT SURGERY Have you ever had surgery for breast cancer or prevention? □ Yes □ No Select all sites of past surgery: □ Left breast □ Lumpectomy / partial mastectomy □ Mastectomy for diagnosed breast cancer (therapeutic) □ Mastectomy for prevention (prophylactic) □ Sentinel lymph node biopsy □ Axillary node dissection □ Right breast □ Lumpectomy / partial mastectomy □ Mastectomy for diagnosed breast cancer (therapeutic) □ Mastectomy for prevention (prophylactic) □ Sentinel lymph node biopsy □ Axillary node dissection □ Ovaries □ Left ovary (oophorectomy) □ Right ovary (oophorectomy) □ Hysterectomy (including oophorectomy) Month/Year __________ __________ __________ __________ __________ Month/Year __________ __________ __________ __________ _________ Month/Year __________ __________ __________ RADIATION THERAPY Have you had radiation therapy for breast cancer? □ Yes Breast Start Date (Month/Year) □ Left breast _____________________ □ Right breast □ No _____________________ Have you ever received radiation for any of the following? □ Hodgkin’s disease □ Thyroid disease □ Lung disease □ Other/I’m not sure: __________________________________ CHEMOTHERAPY Select all chemotherapy treatments received: □ Abraxane®/Carboplatin □ Abraxane®/Xeloda® □ AC (Adriamycin®/Cytoxan®) □ AC followed by Taxol® (Adriamycin®/Cytoxan®/Taxol®) □ AC followed by Taxotere® (Adriamycin®/Cytoxan/Taxotere®) □ CMF (Cytoxan®/Methotrexate/5‐Fluorouracil) (continued) □ □ □ □ □ □ □ □
□ FAC/CAF (5‐Fluorouracil/Adriamycin®/Cytoxan®) FEC (Fluorouracil/Epirubicin/Cytoxan®) Halaven® Ixempra® Ixempra®/Xeloda® TC (Taxotere®/Cytoxan®) TAC (Taxotere®/Adriamycin®/Cytoxan®) Taxol®/Xeloda® Taxotere®/Xeloda® Taxol®/Gemzar® Taxotere®/Carboplatin Taxol®/Carboplatin Other: _______________________________________ Follow‐up questions for chemotherapy treatment: (Additional copies of follow‐up questions are found at the end of this form) Name of treatment: __________________________________ Start date (Year; include month if in the last 12 months): ________________________________ This treatment was received □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): ___________________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □
Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other TARGETED/BIOLOGICAL THERAPY Select ALL targeted/biological therapies taken (alone or in combination with chemotherapy): Herceptin®/Trastuzumab Tykerb®/Lapatinib Avastin®/Bevacizumab Follow‐up questions for biological/targeted therapy: (Additional copies of follow‐up questions are found at the end of this form) Name of treatment: _____________________________ Start date (Year; include month if in the last 12 months): _________________________ This treatment was received □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): _______________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □ Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other ENDOCRINE/HORMONE THERAPY Select all endocrine/hormone therapy received: Anti‐Estrogen Drugs □ Evista®/Raloxifene □ Fareston®/Toremifine □ Faslodex®/Fulvestrant □ Nolvadex®/Tamoxifen Aromatase Inhibitors □ Arimidex®/Anastrozole □ Aromasin®/Exemestane □ Femara®/Letrozole Ovarian Suppression □ Lupron®/Leuprolide □ Plenaxis®/Abarelix □ Suprefact®/Buserelin □ Zoladex®/Goserelin Other Endocrine/HT □ Megace®/Megestrol Acetate Follow‐up questions for Endocrine/Hormone Therapy: (Additional copies of follow‐up questions are found at the end of this form) Name of treatment: ________________________________ Start date (Year; include month if in the last 12 months): ________________________________________ This treatment was received □ Before diagnosis of primary breast cancer □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): __________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □ Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other BISPHOSPONATE OR OTHER THERAPY TO INCREASE BONE DENSITY OR STRENGTH Select ALL medications received: □ Actonel®/Risedronate □ Aredia®/Pamidronate □ Boniva®/Ibandronate □ Fosamex®/Alendronate □ Zometa®/Zoledronate Follow‐up questions for Bisphosphonate Therapy: (Additional copies of follow‐up questions are found at the end of this form) Name of treatment: _________________________________ Start date (Year; include month if in the last 12 months): _______________________ This treatment was received for □ Bone density loss prior to treatment □ Bone density loss related to treatment Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date (Year; include month if in the last 12 months): ________________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □ Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other ADDITIONAL INFORMATION The information you provide in this section is voluntary, and will be used to help improve future service. For more information regarding the safety and privacy of information you provide us, please visit our Privacy Policy. Highest level of completed schooling: □ Less than high school □ High school graduate / GED □ Some college or technical school □ College graduate □ Postgraduate education What is your racial background? □ American Indian or Alaska Native □ Asian □ Black or African American □ Hispanic or Latino □ Native Hawaiian or Other Pacific Islander □ White □ Other Are you of Latino / Hispanic heritage? □ No □ Yes How did you hear about BreastCancerTrials.org (this website)? □ Doctor / nurse / medical team □ Another patient □ Breast cancer support group □ Friend or family member □ Internet: Name of search engine or web site: ______________________________ □ Local or national organization □ Name of organization: □ Radio announcement □ Other: ____________________________________ Additional forms for Treatment Follow‐up Questions Chemotherapy treatment: Name of treatment: ___________________________ Start date (Year; include month if in the last 12 months): ________________________________ This treatment was received □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): ___________________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □
Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other Name of treatment: ___________________________ Start date (Year; include month if in the last 12 months): ________________________________ This treatment was received □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): ___________________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □
Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other Name of treatment: ___________________________ Start date (Year; include month if in the last 12 months): ________________________________ This treatment was received □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): ___________________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □
Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other Biological/targeted therapy: Name of treatment: _____________________________ Start date (Year; include month if in the last 12 months): _________________________ This treatment was received □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): _______________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □ Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other Endocrine/Hormone Therapy: Name of treatment: _______________________ Start date (Year; include month if in the last 12 months): ________________________________________ This treatment was received □ Before diagnosis of primary breast cancer □ Between diagnosis and surgery □ After surgery
Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date ((Year; include month if in the last 12 months): __________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □ Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other Bisphosphonate Therapy: Name of treatment: _________________________________ Start date (Year; include month if in the last 12 months): _______________________ This treatment was received for □ Bone density loss prior to treatment □ Bone density loss related to treatment Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date (Year; include month if in the last 12 months): ________________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □ Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other Name of treatment: _________________________________ Start date (Year; include month if in the last 12 months): _______________________ This treatment was received for □ Bone density loss prior to treatment □ Bone density loss related to treatment Are you currently on this treatment? □ Yes □ No: Completed treatment regimen Treatment end date (Year; include month if in the last 12 months): ________________________ □ No: Discontinued treatment before completing regimen Why did you stop treatment? □ Tumor occurred, recurred, or did not shrink with therapy □ Stopped treatment due to side‐effects of therapy □ I’m not sure/Other