Hormone Replacement Therapy Case Inquiry Form

* denotes required fields
Personal Information
* Name
* Address
City
State
Zip Code
Daytime Phone Number
Evening Phone
Mobile Phone
* E-mail Address
   
Case Information
Exact Date you were diagnosed with breast cancer
 
Name, address and phone number of physician who diagnosed breast cancer
 
Was your breast cancer:
 
Lobular
Ductal
Hormone receptor positive
Hormone receptor negative
Estrogen receptor positive
Estrogen receptor negative
Progesterone receptor positive
Progesterone receptor negative
Did you have a needle biopsy?
 
Yes
No
Date and Place
Did you have an excisional biopsy?
 
Yes
No
Date and Place
Did you have a lumpectomy?
 
Yes
No
Date and Place
Mastectomy, single?
 
Yes
No
Date and Place
Mastectomy, billateral?
 
Yes
No
Date and Place
Other Surgery #1 (describe)
 
Date and Place
Other Surgery #2 (describe)
 
Date and Place
Other Surgery #3 (describe)
 
Date and Place
Other Surgery #4 (describe)
 
Date and Place
Since your breast cancer diagnosis, have you been prescribed any of the following medications:
 
Tamoxifen
Arimidex
Other (please name)
Did you have:
 
Chemotherapy (how long)
Radiation treatments (how long)
Did you have lymph nodes removed?
 
Yes
No
What were the results of testing on the lymph nodes?
 
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.