Formular für die Patientennavigation (Intake…

Aufnahmeformular für Patientennavigation

Füllen Sie bitte das unten stehende Formular für die Patientennavigation aus, um weitere Informationen über Ihren Weg zum Chordom zu erhalten. Dies hilft dem Patienten-Navigator, Ihre Behandlungsgeschichte und die aktuellen Bedürfnisse Ihres Angehörigen zu verstehen, damit der Navigator Sie bestmöglich unterstützen kann.

Sobald Sie das Formular ausgefüllt haben, wird sich ein Patientennavigator der Chordoma Foundation innerhalb eines Werktages mit Ihnen in Verbindung setzen.

Please select your language.

Your contact information

First name

Last name

Your primary language

Are you the patient?

Patient information

So that we can best assist you, please tell us about yourself and your journey with chordoma.

Age

Gender

Self-description

Date of birth

Date of diagnosis (estimate if needed)

Do you have a family history of cancer or any type of benign tumor?

If yes, please briefly provide more details (type of cancer or tumor, which family member was affected, etc.)

Do you have a personal or family history of any medical conditions that would predispose you to cancer or benign tumors?

If yes, please provide more details (type of condition, which family member, etc.)

Where is or was your primary tumor located?

Skull base (clival)CervicalThoracicLumbarSacral/coccygealMore than one locationDon't know

Which vertebrae are/were involved, if known?

What subtype of chordoma do you have?

Conventional (also called classic)Poorly differentiatedDedifferentiatedChondroidI don't know

Which of the following best describes your chordoma right now:

I have or had a local primary tumor, but no recurrence and no metastasis My primary tumor has been treated and has recurred in the same areaMy tumor has spread to other locations on the spine or other parts of the body, but can still be treated with surgery or radiationI have tumor(s) that can no longer be treated by surgery or radiation

Do you have:

Location of metastases (choose all that apply):

SpineOther bonesLung(s)LiverSkinSoft tissueOther

Which of the following describes the current growth of your tumor:

StableProgressingNo tumor can be seen on my scans

Have you ever had treatment for your chordoma?

What treatments have you received?

SurgeryRadiationDrug therapyClinical trial

Please tell us more about which drug therapy or clinical trial, and your outcome.

Right now are you:

Preparing for treatmentIn active treatmentMonitoring

Please share any other details about yourself or your treatment that you'd like us to know (dates of treatment, outcome, where treatments were received, etc,)

Caregiver's name

Caregiver's relationship to you

Spouse/partnerParentChildFamily memberFriendOther

Patient's information

So that we can best assist you, please tell us about your loved one's journey with chordoma. All questions in this section refer to the patient unless otherwise noted.

First Name

Last Name

Patient's City

Patient's Country

State (Australia)

Federative Unit (Brazil)

Province (Canada)

Province (China)

County (Ireland)

State or Union Territory (India)

Province (Italy)

State (Mexico)

State (United States)

Age (estimate if needed)

Gender

Self-description

Date of diagnosis (estimate if needed)

Primary language spoken by patient

Where is or was the patient's primary tumor located?

Skull base (clival)CervicalThoracicLumbarSacral/coccygealMore than one locationDon't know

Which vertebrae are/were involved, if known?

What subtype of chordoma does the patient have?

Conventional (also called classic)Poorly differentiatedDedifferentiatedChondroidI don't know

Which of the following best describes the patient's chordoma right now:

Patient has or had a local primary tumor, but no recurrence and no metastasis (tumor in other places) Patient's primary tumor has been treated and has recurred in the same areaPatient's tumor has spread to other locations on the spine or other parts of the body, but can still be treated with surgery or radiationPatient's tumor(s) can no longer be treated with surgery or radiation

Does the patient have:

Location of metastases (choose all that apply):

SpineOther bonesLung(s)LiverSkinSoft tissueOther

Which of the following describes the current growth of the patient's tumor:

StableProgressingNo tumor can be seen on scans

Has the patient ever had treatment for chordoma?

What treatments has the patient received?

SurgeryRadiationDrug therapyClinical trial

Please tell us more about which drug or clinical trial, and the patient's outcome.

Right now the patient is:

Preparing for treatmentIn active treatmentMonitoring

Please share any other details about the patient or his/her treatment that you'd like us to know (dates of treatment, outcome, where treatments were received, etc.)

Does the patient have a family history of cancer or any type of benign tumor?

If yes, please briefly provide any details you are aware of (type of cancer or tumor, which family member was affected, etc.)

Does the patient have personal or family history of any medical conditions that would predispose him or her to cancer or benign tumors?

If yes, please briefly provide any details you are aware of (type of condition, which family member was affected, etc.)

Are you the primary caregiver?

Caregiver's name

Caregiver's relationship to patient

Spouse/partnerParentChildFamily memberFriendOther

Patient Navigation Service - How can we help you?

Which of the following would you like more information about? (select all that apply)

How chordoma should be treated

Doctors who have experience treating chordoma

Finding a clinical trial (for patients with advanced or metastatic chordoma)

Resources for travel or housing assistance (if traveling for treatment)

Donating tumor tissue through the CF Tumor Donation Program

Connecting with other patients and family members

Dealing with symptoms and side effects such as pain, fatigue, etc.

What symptoms and side effects are you experiencing?

What symptoms and side effects is the patient experiencing?

What other information needs do you have at this time?

Terms of Service

By checking the box below and submitting this form, you consent to be contacted by a Patient Navigator from the Chordoma Foundation. After you click on the submit button below, your information will be sent to a Chordoma Foundation Patient Navigator. The Patient Navigator will contact you within 1-2 business days to assist you with information and resources that can help meet the needs indicated in this form.

I agree that I have provided the information in this form for the purpose of receiving (1) patient navigation services and (2) information on the needs I indicated above. I understand that the information I provided in this form will be used for these purposes only.

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Contact Information