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20. WHAT WAS YOUR «PT;RSON'S» DATi/ OF <br />DT/ATH? <br />21. WHAT STAT>; DH) YOUR «PI;RSON» <br />LIVE IN AT TIMI; OF DT;ATH? <br />22. MAY WE INTI',RVIT/W YOU ABOUT YOUR <br />«P1;RSON'S» CANCTJR DIAGNOSIS? <br />23. WHAT IS /WAS YOUR <br />«P>;RSON'S» NAMT; <br />FIRST NAME <br />24. WHAT IS/WAS YOUR «P>;RSON'S» DOB? <br />25. WHAT IS/WAS YOUR «P>JRSON'S» GI+;ND1;R? <br />26. WHAT IS/WAS YOUR «PT/RSON'S» RACE? <br />27. WHAT YEAR WAS THIr CANCER DIAGNOSED? <br />a~ <br />MM/DD/YYYY <br />^ YES ^ NO <br />LAST NAME <br />MM/DD/YYYY <br />^ MALE ^ FEMALE <br /> YYYY <br />28. W HAT TYPE OF CANC>;R WAS DIAGNOSED? <br />^ BLADDER (URINARY) ^ SKIN -MELANOMA <br />^ BRAIN ^ SKIN -BASAL CELL <br />^ BREAST ^ SKIN - SQUAMOUS CELL <br />^ COLON OR RECTAL ^ OVARIAN <br />^ ESOPHAGEAL ^ PANCREATIC <br />^ KIDNEY (RENAL) ^ PROSTATE <br />^ LEUKEMIA ^ STOMACH <br />^ LIVER (Including Intrahepatic Bile Duct) ^ UTERINE (Including Cervix or Corpus) <br />^ LUNG (Including Bronchus) ^ OTHER: <br />^ LYMPHOMA (Including Non-Hodgltin) <br />29. IS TH>; CANC>;R ACTIV); OR IN R>MISSION? ^ ACTIVE ^ REMISSION <br />30. WHO IS /WAS YOUR <br />«PI;RSON'S» <br />PRIMARY PHYSICIAN? <br />FIRST NAME <br />31. WHO I5 /WAS <br />YOUR «pERSON'S» <br />ONCOLOGIST? <br />FIRST NAME <br />LAST NAME <br />LAST NAME <br />Page 23 of 47 <br />