Your Name

Date of Birth

Phone

eMail

Mailing Address

Name

Phone Number

Email

physician
Address

Instructions

What is your gender ? Male Female

What is your self-described race ? White Black Asian Other
If other, please specify

What is your Blood Type ?
A+ A- B+ B- AB+ AB- O + O - Don't Know

Do you have a cancer that affects your blood or bone marrow ? Yes No

Do you have a brain tumor or has your cancer spread to your brain ? Yes No

Are you capable of caring for yourself ? Yes No

Do you have diabetes ? Yes No

Do you have a history of heart problems ? Yes No

Have you ever been pregnant ? Yes No
if YES, how many times ? 1 2 3 4 or more

Are you currently pregnant or nursing ? Yes No

Have you ever been treated with Fludarabine ? Yes No

Have your ever received blood products or bone marrow / stem cell transplants ?
Yes No Don't Know

What is the stage of your Disease ? 1 2 3 4 Don't Know

Section 1 - List all medications, including any vitamin or herbal supplements you have take over the past 30 days

Section 2 - Briefly give a synopsis of your disease and all treatments. Include the month/year of your diagnosis, type of cancer, types of treatment you received (e.g. chema, radiations) and all surgeries you had related to the cancer

Thank you!