First Name : Enter a first name, initial, or nickname.
Middle Initial :
Last Name : If you prefer anonymity, enter a last initial.
Relationship To Patient : Enter 'self' if you are the patient.
Email Address : If you prefer anonymity, leave this blank.
Anonymous Email : For anonymity, enter email address here. It will remain unpublished.
Birth Date : Enter as yyyy-mm-dd, this will not be published.
Diagnosis Date : Enter as yyyy-mm-dd.
Diagnosis Age : Enter as yy.
Primary Body Site : The body site where your AdCC started.
Wrong Diagnosis : If you had an incorrect diagnosis (ie. chronic sinus infections), input it here.
Surgical Treatment : Enter all surgeries, include dates.
Radiation Treatments : Enter all types of radiation, include dates.
Chemotherapy Treatments : Enter all chemotheraphy treatments, include drugs used and dates.
Alternative Treatments : Enter information on alternative treatments used.
Other Treatments : Enter any other forms of treatment you received.
Surgeons : Enter surgeons who have treated your cancer.
ENT : Enter ear nose and throat specialists who have treated your cancer.
Medical Oncologists : Enter all medical oncologists who have treated you.
radiation_oncologists : Enter all radition oncologists who have treated you.
Other Professionals : Enter any other medical professionals who have treated your cancer.
Treatment Center 1 : Enter the first facility or cancer care center that treated your cancer.
Treatment Center 2 : Enter the second facility or cancer care center that treated your cancer.
Treatment Center 3 : Enter the third facility or cancer care center that treated your cancer.
Other Centers : Enter any other facilities that have treated your cancer.
Regrowth Date 1 : Regrowth is a recurrence in the original body site. Enter as yyyy-mm-dd
Regrowth Date 2 : Enter as yyyy-mm-dd
Regrowth Comments : Enter any information on your recurrence.
Metastasize Date 1 : Enter as yyyy-mm-dd
Metastasize Date 2 : Enter as yyyy-mm-dd
Other Metastasize : Enter additional metastasize dates here.
Metastasize Body Site 1 : Enter first metastasize body site here.
Metastasize Body Site 2 : Enter second metastasize body site here.
Other Body Sites : Enter additional metastasize body sites here.
Genetic Testing : Enter any gene or dna testing information here.
Tumor Testing : Enter any tumor block testing information here.
Other Specialized Tests : Enter any other tumor or specialized tests done on your cancer.
Geographic Residence : Enter your geographic area of residence.
Familial Factors : Enter items that you believe affected your cancer.
Environmental Factors : Enter items that may have affected your cancer.
Other Illnesses : Enter any major or chronic illnesses other than your cancer.
Deceased Date : Enter as yyyy-mm-dd
Other Information : Enter other info not listed above.
