Terms and Agreements
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I certify that I have read, in a language that I understand, all of the components of this form. I understand that my decision to participate will help the community by bringing into limelight the untapped scenarios on late detection, thus helping to save lives. The information I am providing is accurate based on my knowledge.
By signing my name below, I am indicating that I have read and understand the parameters of the study.
Name of the witness, Relationship with the Participant, Address of the witness
Date
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Date Format - Month Day Year
MM
DD
YYYY
Participant Name
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First Name
Last Name
Address of the participant
Phone
Please include the area code as well.
Country
(###)
###
####
Email
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Country, State, City of residence
What is your biological sex
Male
Female
Other
If other, please specify
What is your age in number?
What is your race or ethnicity? Your mother tongue?
How was your treatment paid for? Please indicate if you have insurance, if you paid out of pocket, if your treatment was supported by government schemes, etc?
For those who were diagnosed with breast cancer, how was the cancer in your breast identified the first time?
Breast Self Examination
Clinical Breast Examination
Mammogram
3D Mammogram
Ultrasound
Other
If cancer identified in another way, please specify
When you had breast cancer for the first time, which breast did your cancer present in?
Right
Left
Both
I don't know
I never had Breast Cancer
If diagnosed with Breast Cancer, do you know if you have dense breast? If so, did you have an additional screening apart from mammogram (please specify what type if yes)?
When you were diagnosed with cancer, do you feel like financial constraints affected your treatment? How did you manage the expenses?
If you had/ have breast cancer, do/did you have any of the following types of breast cancer?
Ductal carcinoma in situ
Lobular carcinoma in situ
Mixed ductal and lobular
I'm not sure
What was your approximate weight in pounds and height in feet at the time of your first cancer diagnosis ?
If female, did you ever take hormonal contraceptive, undergo hormone replacement therapy, or receive any other hormonal treatments before your diagnosis? If male, did you receive any hormonal treatments before your diagnosis? If yes to any of these questions, please specify what treatments were received.
If female, were you ever pregnant? If so, how many pregnancies did you have before you got cancer for the first time?
If Female, How many children did you give birth to?
If Female, Do you have a history of miscarriage?
What is your medical history? Do you have any chronic illnesses other than cancer (including inflammatory diseases like arthritis)?
Do you have a family history of cancer? If so, what types of cancer?
Do you have Family history of Breast or ovarian Cancer? If yes, did you perform any genetic testing? For Example - BRCA2, BRCA2 and others? Please explain
Do you know if you had any genetic testing done in regards to your cancer? If so, please indicate what mutations were found (if none were found, please type "none")?
What stage of breast cancer were you diagnosed at the first time that you were diagnosed with breast cancer?
What stage was your cancer as of March 2021?
When were you first diagnosed with breast cancer (approximate)?
What is your estrogen receptor status?
Positive
Negative
I do not know
What is your Progesterone receptor status?
Positive
Negative
I do not know
Are you HER2 positive?
Yes
No
I do not know
What is the grade of the tumor?
Grade 1
Grade 2
Grade 3
I do not know
What was the surgical procedures/treatment methods/ medications used to address your cancer?
Did you use ayurveda, homeopathy, or any kind of alternative medicine with your conventional cancer treatment? Explain
Did you delay your conventional cancer treatment (surgery, chemotherapy, radiation, etc) and go for ayurveda, homeopathy, or other alternative medicine treatment methods? Please specify if the alternative medicine treatment had worked or if the cancer got worse/ remained unchanged.
Did you consume tobacco in any form prior to your diagnosis? If so, please specify how it was consumed (smoking, vaping, chewing, sniffing, hookah, supari (areca nut), paan, hookah, slaked lime, etc)
Do you still continue to use tobacco in any form?
Did you regularly drink alcohol prior to you diagnosis? If so, how many drinks did you consume per week?
Did you consume alcohol after your cancer diagnosis?
Did you exercise before your cancer diagnosis? If yes, please indicate how many minutes per week.
Did/do you regularly exercise after your cancer diagnosis? If yes, please indicate for how long in minutes per week.
What form of exercise(s) did you take part in before your cancer diagnosis?
What form of exercise(s) do/did you partake in after your cancer diagnosis? (Leave blank if not applicable)
What was your diet like before cancer? Did you feel that it was healthy/ balanced? Did you take part in any special kinds of diets like counting macros, keto, intermittent fasting, etc?
How would you rate your stress levels before your cancer diagnosis?
Option One
Option Two
Did your cancer present as ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), both, or neither?
If your cancer has relapsed, what stage are you in now? Were you declared cancer free earlier? Or did your cancer progress from nonmetastatic (stage 0, 1, 2, 3) to metastatic (stage 4)?
