Microsoft word - mentor application_updted do not use

Mentor Application
Thank you for your interest in becoming an ABCD mentor. If you’ve had breast cancer, we recommend that you are at least one year beyond treatment to begin training. To become a mentor, you must complete ABCD’s New Mentor Training program. You then will be matched with participants on the basis of such characteristics as age, diagnosis and treatment. Your responses to this questionnaire will help us match you with breast cancer patients. All information is confidential. Feel free to attach an additional page if you need more space to answer these questions. Thank you! ABCD: After Breast Cancer Diagnosis
Section I: General Information
Date of Birth
Marital Status:
Single never married / divorced / widowed Were you employed when you were diagnosed? What was your marital status when you were Single never married / divorced / widowed Number of Children
How important was religion/spirituality in your healing process? Do you, or did you, deal with any psychological issues (depression, family conflicts, etc.) related to your breast cancer? (optional) Please list your outside interests and hobbies: Are you fluent in any foreign languages? Section II: Diagnosis

Date of diagnosis
Age at diagnosis
Menopausal stage at diagnosis
Was this diagnosis a
How was your cancer discovered?

Tumor Size
Tumor Grade
Lymph Node Involvement Yes / No (If yes: Number of positive nodes)
Was your breast cancer:
Hormone receptor-positive: ER+ Yes / No PR+ Yes / No
HER2-positive (HER2+) Yes / No
Triple Negative Yes / No
Gene Testing:
Have you undergone genetic testing to determine if you are/were at increased risk for breast cancer? Yes / No Did you test positive for BRCA1 Yes / No BRCA2 Yes / No
Did you choose to get a second opinion at any point during your breast cancer experience? Yes / No
Please list any other tests and/or results that you are aware of regarding your breast cancer diagnosis,
or any other experience you had while being diagnosed, that you feel would be helpful for us to know:

Section III: Surgeries
Did you have any surgical biopsy procedures? Yes / No Lymph Node Surgery:
Breast Surgery:
Reconstruction: Yes / No
Delayed How long?
Tissue Flap
TRAM flap pedicle flap / free flap / don’t know (Skin, fat, blood vessels, and at least one abdominal muscle are moved from the abdomen to the chest.) (Uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound.) (Moves muscle and skin from the upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast.) (Uses tissue from the buttocks, including the gluteal muscle, to create the breast shape.) Implants
Silicone gel-filled
One-stage immediate breast reconstruction Two-stage reconstruction with tissue expander(s) Nipple Areola Reconstruction Yes / No
Nipple Areola Tattoo Yes / No
Do you have any additional information regarding your surgeries that you would like us to know? (Please continue on back as needed) Section IV: Treatment
Radiation: Yes / No
Internal/Brachytherapy (5 day) multi-catheter / balloon-catheter (MammoSite) Do you have any additional information regarding your radiation that you would like us to know? Chemotherapy: Yes / No
Adjuvant / after surgery
Neoadjuvant / prior to surgery
If known, please indicate what chemotherapy regimen was used to treat your breast cancer:
AC: Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide)
AT: Adriamycin (doxorubicin)and Taxotere (docetaxel)
TC: Taxotere (docetaxel) and Cytoxan (cyclophosphamide)
TAC: Taxotere (docetaxel), Adriamycin (doxorubicin), and Cytoxan (cyclophosphamide)
AC T: Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide) followed by Taxol
(paclitaxel) or Taxotere (docetaxel)
CMF: Cytoxan (cyclophosphamide), methotrexate, and 5-Fluorouracil
A CMF: Adriamycin (doxorubicin), followed by CMF
FAC or CAF: 5-Fluorouracil, Adriamycin (doxorubicin), and Cytoxan (cyclophosphamide)
(The FAC and CAF regimens use the same medicines but use different doses and frequencies) CEF (FEC): Cytoxan (cyclophosphamide), Ellence (epirubicin), and 5-Fluorouracil
Do you have any additional information regarding your chemotherapy that you would like us to know? Targeted Therapies: Yes / No
(Treatments that target specific characteristics of cancer cells)
Hormonal Therapies: Yes / No
(Medicines used to treat hormone-receptor positive breast cancers)
Selective estrogen receptor modulators (SERM) tamoxifen (also called tamoxifen citrate; brand name: Nolvadex) Faslodex (fulvestrant) (Used for post-menopausal women diagnosed with advanced (metastatic) hormone- receptor-positive breast cancer that has stopped responding to other hormonal therapy medicines) Please list any details regarding your treatment(s), such as when and how long you were on them, or
if you are still taking it. Did you experience any side effects, or is there any other information that
may be helpful in matching you with a participant?

Section V: Other Information

Other Conditions:
Do you have any other medical conditions, especially those that may have affected your breast cancer
experience, which might be helpful for ABCD to know about (for example, other cancers, diabetes, etc.)?

Complementary / Integrative Therapies:
Please let us know of any complementary therapies and practices you used to help you manage the
physical and emotional symptoms of breast cancer.
Please tell us about any other circumstances you experienced during your breast cancer journey that may make you uniquely qualified to provide one-to-one personalized support to someone. If you have not had breast cancer, what is your personal experience with this disease? Please complete application and bring with you to New Mentor Training, or mail to: ABCD: After Breast Cancer Diagnosis 6737 W. Washington St. Suite #3265 West Allis, WI 53214 (414) 918-9222


Microsoft word - emergency sheet '13.doc

Bow High School * Emergency Information * Parents/ Guardians ~ Please complete and return it to the school nurse. Remember to notify the school immediately of changes in phone numbers and address and notify the school nurse of any health changes; medications, health care providers, illness or medical treatment. Student’s Name: ____________________________________________________

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