Letrozole Study Patient Follow-up

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	Letrozole Study Patient Follow-Up
	Please take time to accurately complete the online application.
First Name:	*
Last Name:	*
Address 1:
Address 2:
City:
State:
Zip:
Country:
Home Phone:
Daytime Phone:	*
email:	*
Retype email:


Breast Cancer Diagnosis

Please indicate current Medical Oncologist:
Doctor's Name:
Doctor's Phone:


Date of Diagnosis:
Stage:
Size:
Histologic Grading:
Histologic Type:
Nuclear Grading:
Estrogen Receptor:
Mitotic Index:
Progesterone Receptor:
Vascular Invasion:
Her 2 Neu Positive:
Lymph Node:

Have you or will you be tested for BrCA1 and BrCA 2 genes?
No I will not be
Yes I will be
Test pending
Both negative
Only BrCA1 positive
Only BrCa2 positive
Both positive
If there were any positives, what are the official results? Will you provide us with the official report?


Have you ever received chemotherapy and/or radiotherapy for cancer?
Yes
No

If yes, specify the type, including name, dose, frequency, number of treatments, and/or radiation treatments.


If yes, provide duration including start and end dates and note any complications.


Have you taken Zoladex(GnRh analogue) while you were receiving chemotherapy and/or radiotherapy?
Yes
No

If yes, provide the duration and dates.


Recurrence

Have you ever had any new tumors (recurrence) since your last IVF treatmentor since initial diagnosis?
Yes
No

If yes, please indicate where the recurrence:


If yes, please indicate what stage:


If yes, please indicate grade:


Have you ever been told in the past, that you have had any of the following? (check all that apply):
Estrogen Receptor	Progesterone Receptor
Her 2 Neu Positive

Have you received any more Chemotherapy since the recurrence?
Yes
No

If yes, please indicate the type of chemotherapy:


Ovarian Function
(please answer the following questions to help us evaluate your ovarian function)

Are you still menstruating?
Yes
No

Are your menstrual periods regular?
Yes
No

If they have become irregular, when did this happen?


Did your menstrual periods stop/become irregular while you were receiving chemo?
Yes
No

If yes, did they return to normal?


If returned to normal, when?


If they have stopped for 3 or more cycles, when was your last menstrual period?


If your menstrual periods stopped and then returned, is the pattern the same as it once was?
Yes
No

How many days between the 1st day of one menstrual period and the 1st day of the next one?


Describe the amount of bleeding?


How many pads/tampons are you using each day?


How many days is your menstrual period?


Have you been told you have become "menopausal" by any physician?
Yes
No

If yes, did they perform any tests and what tests?


Can we obtain those medical test records?
Yes
No

Would you be willing to undergo ovarian reserve testing to see where you stand? This would require a blood test. The blood can be drawn at our center at no cost to you; otherwise, we can fax a requisition, but it may/may not be covered by your insurance.
Yes
No

Pregnancy/Embryo Utilization:
(please answer the following questions about your pregnancy outcome status)

Have you utilized your frozen eggs/embryos?
Yes
No

If yes, with self or surrogate
Self
Surrogate

How many embryos/eggs were used?

Other Enter Other:

How many embryos/eggs survived?

Other Enter Other:

How many embryos/eggs transferred?

Other Enter Other:

How many embryos/eggs refrozen?

Other Enter Other:

What was ultrasound outcome?
Singleton
Multiple
Other Enter Other:

Pregnancy outcome?


Liveborn infant?
Yes
No

Gestational age reached (number weeks pregnancy progressed)?


Was there any pregnancy complications:
Yes
No

If yes, explain the pregnancy complication.


High blood pressure or pre-eclampsia?
Yes
No

Gestational Diabetes?
Yes
No

If Gestational Diabetes, did you require insulin?
Yes
No

Was there any birth complication?
Yes
No

If yes, please explain birth complication.


What was the Neonatal outcome.


What was the Apgar Score at 1 minute.


What was the Apgar Score at 5 minutes.


What was the weight.


Was there a Neonatal ICU stay?
Yes
No

Number of days for the Neonatal ICU stay.


Explain the procedures.

Breast Cancer Diagnosis

Recurrence

Ovarian Function

Pregnancy/Embryo Utilization: