Be Bright Pink

The PinkPal staff has put a lot of thought into the criteria that a candidate must possess in order to be qualified to become a PinkPal. In order to be considered a candidate, it is critical that you possess the following characteristics:

Has partnered with one or more medical professionals to develop a strategy for assessing and being proactive with one's risk of developing breast/ovarian cancer.
Is high risk for breast and ovarian cancer and has undergone genetic testing with positive, negative, or inconclusive results.
Is at least 6 months post genetic testing.
Is at least 6 months post cancer treatment (if a cancer survivor).

***In order to become a PinkPal, you must fit all criteria above.

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)

Home 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 PinkPal?

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:

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?

Please provide any other details you would like to share.

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?

Please provide any other details you would like to share.

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?

Why are you are interested in volunteering as a PinkPal?

What makes you qualified to be a PinkPal?

Please provide any additional information/comments below: