Be Bright Pink

BE BRILLIANT. BE BOLD. BE CONNECTED.

It's our little secret! Bright Pink will use the following information to keep you informed and up to date on organization updates, programs and activities that we feel will be relevant to you. Bright Pink keeps all information supplied below completely confidential and does not provide access of this information to any third-party.

First Name

Last Name

E-mail Address

(If possible, please enter a personal email address because some
workplace servers may not allow access on the emails we send)

Street Address

Home Address 2

City

State/Province

Zip Code

Date of Birth
( mm/dd/yyyy )

Gender

Female

Male

Marital Status

Single

Married

Divorced

Widow/widower

Other

Race/Ethnicity

Native Hawaiian or other Pacific Islander

Asian

African American or Black

Caucasian or White

Hispanic or Latina

American Indian or Alaskan Native

Other

Explain:

Do you consider yourself to be one or more of the following:

Straight

Gay or lesbian

Bisexual

Transgender

Other

Explain:

How did you hear about Bright Pink?

Health Care Provider

Another Website

Friend or Family Member

Event

Bright Pink publication or brochure

Cause Marketing Product Partnership (i.e. Orbit White, Ice.com)

Search Engine

Facebook

Magazine/Newspaper Article

TV Show/Radio

Other

Explain:

Which of the following categories do you fall into? [Choose all that apply]

Women between ages 20-40 who is/may be at high risk for breast/ovarian cancer

Breast/Ovarian cancer survivor

Friend/Family of a young woman who is/may be at high risk for breast/ovarian cancer

General Supporter

Medical Professional

Journalist or member of the press

What are you most interested in gaining from Bright Pink? [Check all that apply]

Educational information about being pro-active with my health

Involvement in Bright Pink's Peer Support initiative "Pink-Pal"

Opportunity to learn more about genetic testing/Speak with a genetic counselor

Support and opportunity to connect with others who are at high risk for breast and ovarian cancer

Tools to bring a Bright Pink outreach group to your city

Surveillance/Prevention Options to catch cancer early or prevent it altogether

Opportunity to share my experience with others

Information on upcoming events or social activities

Volunteer Opportunities

Other (please explain)

Explain:

Please check all that apply

I have a family history of breast cancer

I have a family history of ovarian cancer

I do not have a family history of breast or ovarian cancer

I do not know if I have a family history of breast/ovarian cancer

I am a breast cancer survivor

I am an ovarian cancer survivor

If checked, how many first degree relatives (as in a mother, father, sibling, or child)

How many second degree relatives (aunts, cousins, grandparents) have had breast cancer?

How many first degree relatives (as in a mother, father, sibling, or child) have had ovarian cancer?

How many second degree relatives (aunts, uncles, cousins, grandparents) have had ovarian cancer?

At what age were you diagnosed with breast cancer?

At what age were you diagnosed with ovarian cancer?

Have you undergone testing for the genetic mutation (BRCA1 or BRCA2)?

Yes, and the results were negative

Yes, and a mutated breast cancer gene was found

Yes, and the results were inconclusive

No, I have not yet decided

No, and I do not intend to be tested

Which of the following is part of your surveillance strategy? Check all that apply

Annual Checkup

Monthly Breast Self Exam

MRI/Ultrasound

CA125 Blood Test

Mammograms

None of the above

Have you ever undergone any surgery to prevent breast cancer?

Yes, I have undergone a bilateral prophylactic mastectomy (preventatively removing breast tissue)

I am considering opting for a bilateral prophylactic mastectomy

No, I have decided not to undergo a bilateral prophylactic mastectomy

I am not considering surgical prevention

Have you ever undergone any surgery to prevent ovarian cancer?

Yes, I have undergone a prophylactic oophorectomy

I am considering opting for the oophorectomy

No, I have decided not to undergo the oophorectomy

I am not considering surgical prevention

Do you have children?

Yes

How many children do you have?

How old are your children?

Are you currently on an oral contraceptive (birth control)?

Yes

I do not wish to share this information

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