Please use the submit button at bottom of page when completed or use printer friendly version of this page and return this form to:
Sisters Network Solano County, P.O. Box 10187, American Canyon, CA 94503
Phone: 707/642-6077 Fax: 707-552-1352
THANK YOU FOR YOUR MEMBERSHIP
Education:
Do you have a family history of breast cancer?
If yes, who?
Do you have any children?
Have you ever had a previous breast biopsy?
Have you had at least one biopsy with atyical hyperplasia?
How was the mass/lump detected?
Before diagnosis were you
Preforming monthly breast self exams (BSE)?
Getting annual clinical breast exams (CBE)?
Having annual mammograms?
HISTORY:
DIAGNOSIS:
TREATMENT:
Radiation Therapy?
Chemotherapy?
Have you had a recurrence?
Do you wear a prosthesis?
Are you considering reconstruction?
Are you interested in special training to educate other people?
The sole purpose of this form is to collect data specifically relating to sisters Network members. This information will be included in a database which will enable SNI to evaluate and determine which factors, such as family history, early detection practices, treatment variances, types and stages of diagnosis, socio-economic factors, and treatment facilities play a pivotal role in breast cancer development, diagnosis, treatment, survivorship and quality of life. All information provided on this form will be kept confidential and access to this information will be strictly regulated and monitored. Your data will be intered into the database under a membership number. Your name will not be included.
