PMP Pals' Network

PMP Pals' Exposures & Behaviors Survey
RequiredRequired Question(s)

Thank you for answering today's survey regarding environmental exposures, personal behaviors, and/or family medical histories that may have affected our health.

This survey is not scientific and has been created specifically for our own interests as patients and family caregivers.

Patients, or their family caregivers/spouses may respond; one respondent per patient, please.

 


 

 
1.

How much time transpired between the onset of symptoms did you (or the patient you are answering for) seek medical care?

Less than one month
One to three months
Three to six months
Six months to one year
One year or more
  • Comment:

  • 500 characters left.
Required 2.

What is your diagnosis, or the diagnosis of the patient you are answering for?

Appendix cancer
Pseudomyxoma Peritonei originating with Appendix Cancer
Peritoneal Carcinomatosis originating with Appendix Cancer
Mucinous Adenocarcinoma originating with Appendix Cancer
DPAM originating with Appendix cancer
Pseudomyxoma Peritonei originating with Ovarian cancer
Mesothelioma
Peritoneal Surface Malignancy not noted above
Signet Ring Cell
Other  
  • Comment:

  • 500 characters left.
3.

Environmental; prior to becoming symptomatic, were you, or the patient you are answering for, exposed to any of the following?

Asbestos
Pesticides, personal (home) or professional use, proximity to agricultural use?
Military service, Iraq/Afghanistan, Gulf War, Viet Nam, etc.
Radiation for diagnostic purposes, x rays, CT scans, etc
Radiation for profession, X ray Technician, Lab Technician, Chernobyl clean up
Radiation environmental, residential proximity to power plant, nuclear waste
Chemical, other occupational or environmental
Oil refinery, proximity residential or employee
H Pylori bacteria
Other  
  • Comment:

  • 500 characters left.
4.

Behavioral; prior to becoming symptomatic, did you, or the patient you are answering for, experience any of the following behaviors?

Cigarette smoking
Consumed more than 2 alcoholic beverages per day
Consumed low fiber, high fat diet
Wore tight jeans, girdles or clothing that restricted abdomen
Vigorous abdominal exercises, "crunches", rowing, sit ups, coitus
Other  
  • Comment:

  • 500 characters left.
5.

Familial; have you, or the patient you are answering for, been diagnosed with any of the following? Have your siblings, parents or children been diagnosed with any of the following?

Crohn's Disease
IBS: Irritable Bowel Syndrome
Celiac Disease
Diverticulitis
UC: Ulcerative Colitis
Colon cancer/colorectal cancer
Lynch Syndrome
Scoliosis
Gall Bladder Disease
Other  
  • Comment:

  • 500 characters left.
6.

How much time transpired between you seeking medical care for your symptoms and you receiving the correct, accurate diagnosis?

Less than one month
One to three months
Three months to six months
Six months to one year
One year or longer
  • Comment:

  • 500 characters left.
7.

How old were you, or the patient you are answering for, when you first noticed your symptoms?

Less than 20 years of age
20 to 30 years of age
30 to 40 years of age
40 to 50 years of age
50 to 60 years of age
60 to 70 years of age
70 to 80 years of age
8 to 90 years of age
Other  
  • Comment:

  • 500 characters left.
8.

What is your gender, or the gender of the patient you are answering for?

Male
Female