Young Women Website Profiles

Thank you for your interest in sharing your experience as a young woman affected by breast cancer.

Please note that all information submitted to LBBC is confidential. Thank you!

*indicates a required answer

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* 1. Contact Information

Name: *

City/Town: *

State:

Country: *

Email Address: *

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* 2. Year of Birth (Please format as 4 digit year. Example: 1982)

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* 3. Year of Diagnosis (Please format as 4 digit year. Example: 2009)

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* 4. Have you been diagnosed with metastatic breast cancer? (choose one)

Yes

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* 5. If yes, what year were you diagnosed with metastatic breast cancer?(Please format as 4 digit year. Example: 2007)

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* 6. Have you been diagnosed with triple-negative breast cancer? (choose one)

Yes

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* 7. Have you undergone the genetic testing process? (choose one)

Yes

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* 8. Have you had breast reconstruction? (choose one)

Yes

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* 9. Are you currently: (choose one)

Single

Married

Divorced

In a Committed Relationship

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* 10. Do you have children: (choose one)

Yes

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* 11. If yes, did you have children: (choose one)

Before your diagnosis

After your diagnosis

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* 12. Please check any of the options you explored to bring a child into your family: (choose all that apply)

Adoption

IVF

Freeze fertilized eggs prior to treatment

Surrogacy

Other (please specify)

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* 13. If comfortable to disclose, do you identify as: (choose one)

Heterosexual

Gay

Lesbian

Bisexual

Transgender

Other (please specify)

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* 14. If comfortable to disclose, what racial or ethnic background do you most closely identify with? (choose one)

African-American

Asian

Hispanic or Latino

Multi-racial/Multi-ethnic background

Native American

Pacific Islander

White, not Hispanic or Latino

Other (please specify)

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* 15. Please provide a short summary of your breast cancer diagnosis and treatment. Please also include any peer or social support you accessed since being diagnosed with breast cancer (i.e. support groups, etc.). Thank you.