Patient Age

Patient Gender

	Male
	Female

Diagnosis

-- Select -- Mucinous Adenocarcinoma of the Appendix Mucinous Cystadenoma of the Appendix Pseudomyxoma Peritonei originating in the Appendix Malignant Ascites Mesothelioma Peritoneal Carcinomatosis Signet Ring Cell Peritoneal Mucinous Carcinomatosis Mucinous Cyst Carcinoma

Date of Diagnosis

Optional (but helpful in case we need to contact you!)

	Name:
	Email Address:
	Phone:
	Surgeon/Oncologist's Name:
	Surgeon/Oncologist's Email:

Celebrex Dosage

-- Select -- 100 mg every 12 hours 200 mg every 12 hours 400 mg every 12 hours

Are you taking Xeloda in conjunction with Celebrex?

	Yes
	No

If so, which dosage of Xeloda are you taking?

-- Select -- 500 mg every 12 hours 1000 mg every 12 hours 1300 mg every 12 hours 1600 mg every 12 hours 1800 mg every 12 hours

Length of time you have taken Celebrex

	One month
	Three months
	Six months
	Nine months
	Twelve months
	Fifteen months
	Eighteen months

Have your tumor marker levels decreased since you began taking Celebrex?

	Yes
	No

Have your physical symptoms improved (decreased pain, bloating, etc.) since you began taking Celebrex?

	Yes
	No

Has visible disease on your CT scans decreased since you began taking Celebrex?"

	Yes
	No