Gender

	Male
	Female

Current Age

-- Select -- 20-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 75+

Age at Diagnosis

-- Select -- 20-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 75+

Which symptom prompted you to seek medical care, leading to your diagnosis?

-- Select -- Abdominal bloating/distension Abdominal pain Bowel distress Hernia Infertility Weight gain or loss

How long has it been since you were diagnosed?

-- Select -- Less than 1 year 1 to 3 years 3 to 5 years 5 to 10 years 10 to 15 years 15 years or more

Diagnosis

-- Select -- Adenocarcinoma of the Appendix Appendiceal Carcinoma Goblet Cell Carcinoid Mesothelioma Mucinous Adenocarcinoma Mucinous Cystadenoma Mucinous Cyst Adenocarcinoma Peritoneal Adenomucinous Peritoneal Carcinomatosis Peritoneal Mucinous Carcinomatosis Pseudomyxoma Peritonei Signet Ring Cell

How many PMP related surgeries have you experienced?

-- Select -- 1 2 3 4 5 6 7 8 or more

Who performed your major cytoreductive surgery(ies)?

	Dr. Richard Alexander
	Dr. David Bartlett
	Dr. Philip Crowe
	Dr. Steven Libutti
	Dr. Brian Loggie
	Dr. Andrew Lowy
	Dr. Paul Mansfield
	Mayo Clinic
	Dr. Brendan Moran
	Dr. Paul Sugarbaker
	Other:

Do you have, or have you had, an ostomy?

	Yes
	No

Chemotherapy: If you have been treated with chemotherapy, how was it administered?

	Systemic
	Intraperitoneal
	Oral

Which type(s) of chemotherapy have you been treated with?

	5 FU
	Campostar (CPT 11)
	Celebrex (Cox - 2 Inhibitor usually taken in conjunction with Chemotherapy)
	Cisplatin
	Mitamycin
	Oxaliplatin
	Saltz Regimen
	Xeloda (Capecitabine)
	Other:

For patients who where diagnosed five or more years ago; has chemotherapy been effective in eliminating your disease?

	Yes
	No

Family History: Have any members of your immediate family been diagnosed with cancer?

	Siblings
	Parents

Do you, or any members of your immediate family, have a history of:

	Appendicitis
	Celiac disease
	Colon Cancer
	Diverticulitis
	Gall Bladder Disease
	Irritable Bowel Syndrome

Exposure to possible hazards: Have you been exposed to situations or substances that you believe may have contributed to your illness?

	Agent Orange
	Asbestos
	Chemical exposure during military service
	Cigarette smoke
	Mother took DES during pregnancy
	Nuclear Waste
	Pesticides
	X Ray exposure
	Other:

Complimentary Medicine: Do you use any of the following as part of your healthcare plan?

	Specialized diet
	Vitamins
	Herbs
	Spiritual; including prayer and meditation
	Other:

Challenges: In facing this disease, which causes you the most challenges?

	Mental stress
	Physical distress

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