*Name: |
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*Street Address: |
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*City: |
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*State |
Zip Code:
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*Phone Number: |
(
)
-
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Best time to contact: |
am
pm |
E-Mail Address: |
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Birthdate: |
/
/
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Place of Birth: |
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The
following describes me: (OPTIONAL; Check all that apply) |
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I have Prostate Cancer (PrCa) |
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I had Prostate Cancer (PrCa) |
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I have family members with PrCa |
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I had family members with PrCa |
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The following family members have/had PrCa (Please check all that apply):
Grandfather
Father
Brother
(No.
of affected brothers
)
Nephew
Uncle
Cousin
Other (Relation:
|
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I have family members with Breast
Cancer |
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I had family members with Breast
Cancer |