FIND Questionnaire from GlobalCures

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Version 5

Who we are

GlobalCures is a non-profit medical research organization made up of scientists and doctors who have been personally affected by cancer and are committed to helping cancer patients. One of our missions is to disseminate information about safe, readily available, and inexpensive off-patent drugs and supplements that may extend survival and improve quality of life.

This questionnaire is part of the FIND program and it helps us to provide information about promising therapies. It is quite short and should take less than 15 minutes to complete.

Your information

Email address *

Name

Birth year

Gender

Female

Male

Other:

Clear selection

Permissions

The FIND Program *

By answering a few questions about your diagnosis, GlobalCures will provide you with a list of promising therapies and their supportive literature. Promising therapies are scientifically sound ideas for which there are limited human studies or data from animal research.

I am voluntarily providing my personal information to GlobalCures staff. I understand that GlobalCures does not guarantee the confidentiality of this information. Therefore, I have not submitted any information that I require to be kept confidential.

Required

The SHARE Program *

The SHARE Program is a collective, patient-driven discovery effort. By donating your data, GlobalCures will be able to combine it with other patient shared data and analyze it to uncover novel ideas for therapies that can be tested formally in clinical trials.

I am willing to participate in the patient sponsored SHARE Program by providing additional and my on-going treatment information.

I do NOT wish to participate in the SHARE Program.

Required

Your disease

Type of cancer *

Breast

Prostate

Colorectal

Lung

Other:

Stage of your cancer (if applicable)

III

Not sure

Other:

Clear selection

Has the cancer spread to other organs?

Yes

Lung

Liver

Brain

Other:

Current treatment status

Newly diagnosed patient awaiting conventional treatment

Currently undergoing conventional treatment

Completed conventional therapy, now in remission or stable

Exhausted all conventional treatment options

Other:

Clear selection

Are there known genetic mutations in your cancer?

If known, please describe.

Previous Treatments

Have you had surgery?

Yes

Tumor completely removed

Tumor partially removed

Tumor is inoperative

Have you received radiation treatment?

Yes

Clear selection

Have you received chemotherapy?

Yes

Clear selection

Have you received any targeted therapy?

Yes

Clear selection

Have you received any hormonal therapy?

Yes

Clear selection

Have you received any therapy recommendations? Please specify.

Medical History

Briefly summarize your medical history by checking the appropriate boxes

Heart Attack (Myocardial Infarction)

Persistent Chest Pain (Unstable Angina)

Abnormal Heart Rhythm (Arrhythmia)

Congestive Heart Failure (CHF)

High Blood Pressure (Hypertension)

Peripheral Vascular Disease

Stroke or Transient Ischemic Attacks (TIA)

Liver Disease (Hepatitis, Cirrhosis)

Diabetes (Uncontrolled Blood Sugar)

Uncontrolled Infection

Autoimmune Disease (Lupus, Hashimoto, etc)

HIV Infection

Other:

Current Performance Status

Describe your current level of activity

Fully active, able to carry on all pre-disease performance without restriction

Restricted in physically strenuous activity, but able to carry out light house/office work

Capable of self-care, but unable to carry out any work activities

Capable of only limited self-care, confined to bed/chair more than 50% of waking hours

Completely disabled, cannot carry on any self-care, totally confined to bed or chair

Other:

Clear selection

Patient's Notes

Provide any other relevant information regarding your treatments, blood tests, etc

Is there anything else you would like to share with GlobalCures?

info@global-cures.org

Housekeeping

The following information is for our records and lets us know if you wish to receive additional communications from GlobalCures

How did you hear about GlobalCures?

Online search

Online support community

Referral

Other:

Referral's name

If you were referred to GlobalCures by a support community or an individual, please provide the name

Communications with GlobalCures

Would you like to receive future communications from GlobalCures, such as newsletters and announcements?

Yes

Clear selection

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