For PRG| JOIN THE GIRLS

Upon submission and approval your information will be added to the PRG searchable database. This password protected database is used by members to search for other young women by zip code, diagnosis, surgeon and reconstruction type (and others). Thank you for joining!

Once approved, you will receive a welcome email and will be provided with the instructions necessary to begin searching.

Please complete the following questionaire to join Pink Ribbon Girls.

Email / Password

Email Address * Password *

General Information

First Name* Last Name* Street Address* City* State* Zip* Home Phone Number* Work Number Cell Phone Number Do you consider yourself a resident of 'Greater Cincinnati?' Yes
No Level of Education Occupation Marital Status* Race/Ethnicity

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Birthdate* / / How did you hear about PinkRibbonGirls.org(Include description below)? Member
Flyer
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Doctor
Other, please describe (provide member name, etc):

Cancer Specifics

Type of Cancer Date of diagnosis* Age at diagnosis* Multiple Diognosis Yes No One Year Anniversary ??? General/Breast Surgeon's Name* or Other: Oncologist's Name* or Other: Plastic Surgeon's Name* or Other Gynecologist's Name* Other Physician's Name Other Specialty How was your cancer first detected?* (i.e. self-exam, clinical breast exam, mammogram?) Other Detection Method Did you experience any breast pain, tenderness, or discomfort prior to diagnosis?* Yes
No If you experienced breast pain please describe the occurrence * How much time passed between the initial detection and the actual diagnosis?* / / Staging* Diagnosis* DCIS - Ductal Carcinoma InSitu
LCIS - Lobular Carcinoma InSitu
IDC - Infiltrating Ductal Carcinoma
Invasive Lobular
Paget's Disease
Inflammatory
Were there lymph nodes involved, and if so how many?* Yes
No
What was your Estrogen/Progestin Receptor status?* What was your Her2Nu status?* What types of surgery (if any) did you have? * Please check all that apply No Surgery
biopsy - Surgical
biopsy - Core Needle
biopsy - Stereotactic
biopsy - Fine Needle
Lumpectomy
Port Placement
Bilateral Mastectomy
Single Mastectomy
Radical mastectomy
Simple mastectomy
Prophylactic Mastectomy
Sentinel Lymph Node Biopsy
Axillary Lymph Node Biopsy Did you have breast reconstruction? Yes
No
If so what type? Tissue Expanders
Tram Flap
LD Flap
DIEP Flap
Bilateral Reconstruction
Silicone Implants
Saline Implants
Nipple Reconstruction
Areola Tattooing
Radiation Therapy* Yes, type:
No
Chemotherapy?* Yes, type:
No
Hormonal Therapy?* Yes, type:
No
Please list any other types of treatment Have you or your family members undergone genetic testing for BRCA1 or BRCA2?* Yes
No Have you taken part in any Clinical trials?* Yes
No

Family Details

Is there any history of breast/ovarian cancer in your family?* Yes
No
Do you have any siblings with breast cancer?* Yes
No
Spouse's Name Do you have any children?* Yes
No
If so please indicate how many? Child 1 - Name/Details Child 2- Name/Details Child 3- Name/Details Child 4- Name/Details Child 5 - Name/Details

Member Interaction Preferences

The Survivor Network is a searchable database of all Pink Ribbon Girls' members. However, Pink Ribbon Girls respects your right to privacy, if at this particular juncture in your life you would like to become a member and but remain anonymous to other members - please select "No" to the visible to others on the Survivor Network.question below. You can still volunteer for events, access the message board and newsletter archives but not access the database of other members and vice a versa.

Subscribe to Pink Ribbon Girls Email List? Yes
No Visible to other members on the Survivor Network? Yes
No

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