Young Breast Cancer in Colorado Survey
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First Name *
Last Name *
Email address
Phone Number
Age at diagnosis *
Date of birth *
MM
/
DD
/
YYYY
City of diagnosis *
State of diagnosis *
Street address you GREW up at (ages 0-18)
City you GREW up in (ages 0-18) *
Zip code you GREW up in (0-18) *
High School you attended *
Diagnosis
Do you have a family history of breast cancer that you are aware of?
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Do you have a genetic mutation that you are aware of?
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Are you filling out this form for yourself or on behalf of someone else? If it is someone else, please indicate if they are alive or deceased.
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How did you hear about this survey?
Would you like to stay informed with information related to this community monitoring program?
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Notes/Comments:
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