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Screening Form
Please complete the screening form below
First Name
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Last Name
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Phone Number
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Gender
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Date of Birth
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What city do you live in?
What state do you live in?
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What category best describes you?
American Indian or Alaska Native
Asian
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What is your current age?
Do you have a history of cancer?
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No
At what age were you diagnosed with this cancer?
Are you currently on active treatment for this cancer? That means you are undergoing chemotherapy, radiation, planned surgery, or other approaches to treatment.
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No
N/A- I do not have cancer
Please describe what treatment you are currently receiving:
Are you currently receiving hospice or end-of-life care?
Yes
No
Were you diagnosed with cancer as a child?
Yes
No
Do you speak English?
Yes
No
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BCFS00592