YOUNG Breast Cancer in Colorado

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Please take a few minutes to answer the following questionnaire. ALL QUESTIONS ARE OPTIONAL EXCEPT NAME AND AGE AT DIAGNOSIS. It is not mandatory to answer all the questions, so feel free to skip questions you do not want to answer or do not know the answer for. Responses are confidential.

There is demographic info on this questionnaire that we use to identify and map areas that are showing high rates of young breast cancer,. We will mark the location you submit to us on maps that we publish, but your name and responses will be anonymous.

If you are submitting on behalf of someone else (alive or deceased) please list their name and info as your responses.

I am answering this questionnaire as: *

myself

for someone else (alive)

for someone else (deceased)

First and Last Name *

Email (optional)

Phone (optional)

Age at Diagnosis *

Birthday

YYYY

COLORADO ADDRESS where you GREW up or LIVED at during diagnosis. (if you would like to list more than 1, please include others below & indicate your age(s) while living at each)

Colorado High School Attended (if applicable):

City & State where you were diagnosed

Do you have a family history of Breast Cancer?

Yes

Other

Clear selection

Do you have any genetic mutations?

Yes

I don't know

Clear selection

Diagnosis

Would you like to be included on a mailing list and updated on new findings, studies, etc?

Yes

Clear selection

Notes/Comments: Please tell us anything additional about your story that you think is important or that we may want to know.

Thank you for participating in the Young Breast Cancer in Colorado Monitoring Program. Your submission will be included and represented in our maps and data.

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