Lymphoma Support Network Questionnaire

Please provide your contact information below:

First name*

Last name*

Email*

Phone number

By registering, you may receive periodic updates from the Lymphoma Research Foundation. You can update your email preferences at anytime.

Gender

Your Date of Birth*

Month/Day/Year

Street address*

City*

State/Region*

Postal code*

Domestic Status*

Preferred Method of Contact and Time to Contact

Phone

I am interested in the Lymphoma Support Network because:*

What are you looking for in a buddy?*

Lymphoma Subtype*

Adult T-cell Leukemia/Lymphoma

Anaplastic Large Cell Lymphoma

Angioimmunoblastic T-cell Lymphoma

Burkitt Lymphoma

Central Nervous System Lymphoma

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Cutaneous Lymphoma

Diffuse Large B-cell Lymphoma

Follicular Lymphoma

Hodgkin Lymphoma

Mantle Cell Lymphoma

Marginal Zone Lymphoma

Peripheral T-cell Lymphoma

Waldenstrom Macroglobulinemia

Unknown

Please indicate your relationship to lymphoma*

Care Partner

Patient

Date of diagnosis

Month/Day/Year

Doctor(s)

Stage

Grade

Current Health Status (Check all that apply)*

Please make at least 1 selection from the choices below.

No Prior Treatment

Newly Diagnosed

Active Surveillance (watch and wait)

Relapsed/Refractory

In Treatment

Remission

Cancer-Free

Other

Treatment History (Check all that apply)

Active Surveillance

Cellular Therapy

Chemotherapy

Clinical Trial

Immunotherapy or Targeted Therapy

Other

Radiation

Surgery

Please specify the name(s) of previous and/or current treatment(s):

Occupation

Hobbies/Interests

How important is the age of your buddy in matching (1=most important; 5=least important)

How important is the gender of your buddy in matching (1=most important; 5=least important)

How important is the geographic location of your buddy in matching (1=most important; 5=least important)

How important is the treatment of your buddy in matching (1=most important; 5=least important)

How important is the diagnosis of your buddy in matching (1=most important; 5=least important)

Languages Spoken (other than English):

How did you hear about the Lymphoma Support Network?

Additional information, comments or questions:

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:*

Today's date*

Month/Day/Year