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Date of Breast Diagnosis

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The following information helps us personalize Shirley’s Angels support.

Age at Diagnosis

How Cancer was Found -- How Cancer was Found --Monthly self breast checkAccidental self breast checkOB/GYNMammogramSpouseOther

Stage of Breast Cancer -- Stage of Breast Cancer --Stage 0Stage 1Stage IIAStage IIBStage IIIAStage IIIBStage IVUnknown

Type of Breast Cancer -- Type of Breast Cancer --DCISInvasive Ductal CarcinomaLobular CarcinomaInflammatory Breast CancerMedullary CarcinomaMucinous CarcinomaPaget's Desease of the NipplePhyllodes TumorTriple NegativeTubular CarcinomaUnknownI do not have breast cancer

Breast Reconstruction Type -- Breast Reconstruction Type --NoneImplants SalineImplants SiliconeTram FlapOtherUnkown at this time

Surgery -- Surgery --LumpectomyPartial MastectomyModified Radical MastectomyDouble MastectomyProphylactic MastectomyOtherUnknown or Undecided at this time

Current Status -- Current Status --Newly DiagnosedNo evidence of cancerin treatmentlocal recurrenceAdvanced/Metastatic

Did you or will you have -- Did you or will you have --Lymph Node InvolvementRadiation TherapyChemotherapyHormone TherapyOophorectomyClinical Trial ParticipationTreatment Induced MenopauseBreast ReconstructionLymphedemaPhysical TherapyNone of theseUnknown at this time

Hormone Status -- Hormone Status --Estrogen Receptive PositiveEstrogen Receptive NegativeProgesterone Receptive PositiveProgesterone Receptive NegativeUnkown at this time

Lymph Node Dissection Type -- Lymph Node Dissection Type --SentinelAxillaryNoneUnknown at this time

BRCA 1/2 -- BRCA 1/2 --BRCA 1BRCA 2No Known Genetic MutationNot TestedUnknown at this time

Family History of Cancer -- Family History of Cancer --BrotherSisterMotherFatherEither of Mother's ParentsEither of Father's ParentsCousin(s)DaughterSonOtherNone

The following questions are for demographic reporting required by funding sources

Race/Ethnicity -- Race/Ethnicity --CaucasianAfricanAsianHispanicTwo or More Racesother

What is your total combined annual income?

Number of members living in your household