Lymphoma Support Network Questionnaire
Please provide your contact information below:
Title
Title
Mr.
Ms.
Mrs.
Miss
Dr.
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Name:
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First
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Last
Date of Birth:
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Date of Birth:
Month
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2023
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2026
2027
2028
2029
Gender:
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Gender:
Male
Female
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Address:
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Street 1:
Street 2:
City/Town:
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City/Town:
State/Province:
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State/Province:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AS
FM
GU
MH
MP
PR
PW
VI
AA
AE
AP
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
None
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ZIP/Postal Code:
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ZIP/Postal Code:
Email Address:
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Email Address:
Phone Number:
Phone Number:
By registering, you will receive periodic updates from the Lymphoma Research Foundation. You can update your email preferences at anytime.
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Domestic Status:
Please select response
Single
Married
Divorced
Widow/Widower
Best way and time to reach you:
Phone
Email
AM
PM
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Indicate your relationship to lymphoma:
Please select response
Patient/Survivor
Caregiver
If a caregiver, date of birth of the person with lymphoma:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
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31
Year
2039
2038
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2032
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2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1996
1995
1994
1993
1992
1991
1990
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1988
1987
1986
1985
1984
1983
1982
1981
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1978
1977
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1930
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1924
If a caregiver, gender of the person with lymphoma:
Please select response
Male
Female
Date of diagnosis:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
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31
Year
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1959
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1956
1955
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1953
1952
1951
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Doctor(s)
If Hodgkin lymphoma, please select the subtype:
Please select response
Nodular Sclerosis
Mixed Cellularity
Lymphocyte Predominant
Other
I Don't Know
If Non-Hodgkin lymphoma, please select the subtype:
Please select response
Adult T-cell Leukemia/Lymphoma
Anaplastic Large Cell Lymphoma
Angioimmunoblastic T-cell Lymphoma
Burkitt Lymphoma
Central Nervous System Lymphoma
Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
Cutaneous B-cell Lymphoma
Cutaneous T-cell Lymphoma
Diffuse Large B-cell Lymphoma
Follicular Lymphoma
Mantle Cell Lymphoma
Marginal Zone Lymphoma
Peripheral T-Cell Lymphoma NOS
Waldenström Macroglobulinemia
Other
I Don't Know
Stage:
Please select response
I
II
III
IV
Grade:
Please select response
Indolent (slow-growing)
Intermediate
High-grade (aggressive)
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Current Health Status (Check all that apply):
Please make at least 1 selection from the choices below.
Newly diagnosed
Active surveillance (watch and wait)
Relapsed/refractory
In treatment
Remission
Cancer-free
Treatment History (Check all that apply):
Chemotherapy
Immunotherapy or Targeted Therapy
Radiation
Stem Cell or Bone Marrow Transplant
Clinical Trial
Surgery
Other
Please specify the name(s) of previous and/or current treatment(s):
(Maximum response 255 chars, approx. 5 rows of text)
Occupation:
Hobbies/Interests
(Maximum response 255 chars, approx. 5 rows of text)
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Matching Preferences:
Please select response
I would like to be a buddy and give support
I would like to be a buddy and receive support
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What is your current need for a buddy?
Please select response
Uncertain
To establish a mutual on-going friendship
To hear my buddy's experiences with a particular treatment
How important is the age of your buddy in matching (1=most important; 5=least important)
Please select response
1
2
3
4
5
How important is the gender of your buddy in matching (1=most important; 5=least important)
Please select response
1
2
3
4
5
How important is the geographic location of your buddy in matching (1=most important; 5=least important)
Please select response
1
2
3
4
5
How important is the treatment of your buddy in matching (1=most important; 5=least important)
Please select response
1
2
3
4
5
How important is the diagnosis of your buddy in matching (1=most important; 5=least important)
Please select response
1
2
3
4
5
Languages Spoken (other than English):
How did you hear about the Lymphoma Support Network?
Please select response
Email
Healthcare provider
LRF website (lymphoma.org)
Postcard or brochure
Social media
Other (please describe below)
Other, please describe:
Additional information, comments or questions:
(Maximum response 255 chars, approx. 5 rows of text)
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By submitting this form, I hereby authorize LRF to disclose all provided information to any party they so choose for the sole purpose of the Lymphoma Support Network. Please type in your initials if you agree with these terms:
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Today's date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
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5
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29
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31
Year
2039
2038
2037
2036
2035
2034
2033
2032
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2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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2006
2005
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1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
Spam Control Text:
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