Fill Out The Prescreen Questionnaire Online

All material is maintained confidential. After review you will be notified by mail if your family meets the Registry research criteria. You will then be invited to join the Registry and a packet of Registry materials will be mailed to you. Please answer all the questions and hit the submit button at the bottom of the page.

Name: Street:
Town: State:
Zip Code: Phone:
Date of Birth: E-mail:
  1. If you qualify, would you consider enrolling in the Gilda Radner Familial Ovarian Cancer Registry Program?
    Yes  No  Maybe
  2. Have you been diagnosed and/or treated for ovarian cancer?
    Yes  No If yes, age at time of diagnosis:
  3. Have you been diagnosed with a benign ovarian tumor or cysts which needed surgical removal?
    Yes  No

    If yes, age at time of diagnosis:
  4. Have you been diagnosed and/or treated for any cancer other than ovarian cancer?
    Yes  No

    If yes, type of cancer:
  5. Has any blood relative been diagnosed and/or treated for ovarian cancer?
    Yes  No  Don't Know

    If yes, how many relatives:    

    If yes, relative's age at time of diagnosis:
  6. Has any blood relative been diagnosed with a benign ovarian tumor or cysts which need surgical removal?
    Yes  No  Don't Know

    If yes, how many relatives:    

    If yes, age at time of diagnosis:
  7. Has any blood relative, male or female, been diagnosed and/or treated for any cancer other than ovarian cancer?
    Yes  No  Don't Know

    If yes, how many relatives:    

    If yes, age at time of diagnosis: