Information is for research purposes only and will not affect your medical treatment
Today’s date
Patient name
Patient address
Home phone # E-mail address
Date of birth Gender
Ethnicity (please check all that apply)
American Indian/Alaskan
Asian/Pacific Islander
Black/African- American
Caucasian, not Hispanic
Hispanic/Latino, not Caucasian or Black
Middle Eastern/Arabic
Other
Family History
(please list relaionship to anybody in your family with a brain tumor)
Please specify type and relationship
Educational Level
(check highest completed)
Grade/Middle School
High School condition
College/University
Graduate/Professional School
Household Income
(check range of your family’s total household income, in US$)
$0-15,000
$15,001-30,000
$30,001-45,000
$>$45,000
Exposure History
(please list any environmental factor that you fear may have contributed to your condition)
THANK YOU FOR COMPLETING THE QUESTIONAIRE
