Treatment Decision Support Background Information Form completed by: Patient Medical Professional Other If Other - Please Specify: Patient Information: Patient First Name: M.I. Patient Last Name: DOB (MM/DD/YYYY): Race: American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative American or Other Pacific IslanderWhiteI prefer not to specifyOther - Please specify below If Other, Please specify: Last 4 digits of SSN: Address: City: State (Abbr.): Zip Code: Email: Phone(xxx-xxx-xxxx): Oncologist Information: Oncologist First Name: M.I. Oncologist Last Name: Institution: Address: City: State (Abbr.): Zip Code: Email: Phone (xxx-xxx-xxxx): Fax (xxx-xxx-xxxx): How did you hear about Clearity? Please Select Physician/Medical Professional referral Ovarian Cancer Patient referral Friend/Family referral Clearity Website/Clearity Portal Steps Through OC Google Facebook Twitter LinkedIn Online Community Other If Other - Please Specify I am interested in receiving communications from Clearity pertaining to ovarian cancer news/information and Clearity events: Yes No I am interested in receiving information from Clearity about the Steps Through OC program that provides psychosocial/emotional support for ovarian cancer survivors and active caregivers (USA only). Yes No Patient Contact/Caregiver Information First Name: Middle Initial: Last Name: Relationship to patient: Address: City: State (Abbr.): Zip Code: Email: Phone(xxx-xxx-xxxx): Patient History Date of First Diagnosis (MM/DD/YYYY) or (MM/YYYY): Diagnosis Method: CA125 Imaging Procedure (CT, PET/CT, or MRI Scan) Biopsy Paracentesis/Thoracentesis (fluid drainage) Surgery Other – Please specify below If Other - Please Specify Stage: I (A,B,C), II (A,B), III (A,B,C), or IV (A,B): Histological subtype: High Grade Serous Low Grade Serous Clear cell Endometrioid Mucinous Carcinosarcoma (MMMT) Don't Know Other – Please specify below If Other - Please specify: Did you have a blood test performed for inherited BRCA gene mutations? Yes No Don't Know If Yes, please enter result: Did you have your TUMOR tested for gene mutations? This testing is a sequencing analysis and may be called FoundationOne, Strata, Tempus, Caris MI Profile, MSK Impact, Snapshot, etc. Yes No Don't Know If yes, specify the name of the test: What type of treatment information are you looking for? Please check all that apply. Front-line treatment with or without maintenance Treatment for recurrence Maintenance treatment after recurrence Clinical trial options Date of First Surgery (MM/DD/YYYY) or (MM/YYYY): Description: Date of Second Surgery/Biopsy (MM/DD/YYYY) or (MM/YYYY): Description: Date of Third Surgery/Biopsy (MM/DD/YYYY) or (MM/YYYY): Description: Treatments: Have you had chemotherapy, targeted therapy (e.g., PARP inhibitor), or immunotherapy? Yes No Note: If multiple drugs were received in a regimen (e.g., Carboplatin/Paclitaxel), list drugs together. Regimen 1 Drug Name(s): Start Date (MM/DD/YYYY) or (MM/YYYY): End Date (MM/DD/YYYY) or (MM/YYYY): Regimen 2 Drug Name(s): Start Date (MM/DD/YYYY) or (MM/YYYY): End Date (MM/DD/YYYY) or (MM/YYYY): Regimen 3 Drug Name(s): Start Date (MM/DD/YYYY) or (MM/YYYY): End Date (MM/DD/YYYY) or (MM/YYYY): Regimen 4 Drug Name(s): Start Date (MM/DD/YYYY) or (MM/YYYY): End Date (MM/DD/YYYY) or (MM/YYYY): Recurrence(s): Have you had recurrence? Yes No Date (MM/DD/YYYY) or (MM/YYYY): Date (MM/DD/YYYY) or (MM/YYYY): Date (MM/DD/YYYY) or (MM/YYYY): Date (MM/DD/YYYY) or (MM/YYYY): Additional Comments Related to Medical History (e.g., additional treatments, surgeries/biopsies, recurrences) (NOTE: If you have questions, please call 858-657-0282 or contact patientsupport@clearityfoundation.org) By checking this box, you understand that the information you are providing when you complete this form will only be used by The Clearity Foundation to facilitate a more informed discussion with you. None of your protected healthcare information will be used by or shared with any third party.
