Lets Talk Cancer Form

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Lets Talk Cancer Form

Information relating to a cancer diagnosis seeking help for further investigation.

Type n/a in any field not applicable. If you are unable to answer a specific question, please explain in the "other" option or at the end of the form, thank you.

My response will be e-mailed to you using the information provided below.

Email *

First Name *

Last Name *

Date of Birth *

YYYY

Cancer type (be as specific as possible) *

Cancer Staging T *

Other:

Cancer Staging N
*

Other:

Cancer Staging M
*

Other:

Cancer Staging Further

In situ—Abnormal cells are present but have not spread to nearby tissue.

Localized—Cancer is limited to the place where it started, with no sign that it has spread.

Regional—Cancer has spread to nearby lymph nodes, tissues, or organs.

Distant—Cancer has spread to distant parts of the body.

Unknown—There is not enough information to figure out the stage.

Other:

Clear selection

Any histology data/genetical info *

Previous Treatment (select all that apply) *

Chemotherapy

Radiotherapy

Immunotherapy

Surgery (please define below)

Other:

Required

Any currently planned treatment *

How would you consider your diet in general? *

1 - Terrible

2 - Pretty bad

3 - It's OK, fairy balanced

4 - Pretty good majority of the time

5 - Amazing

0 - "What is a diet?"

Other:

Specific Dietary Requirements *

How many times per week do you exercise? *

1-2

2-3

3-5

Do you have any other pre-existing medical conditions? ... *

...If so any current prescriptions? You may already be taking drugs that help stop cancer!
*

Any family history of cancer? *

Any questions or further information for me here...

Submit

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