Screening Form
Please complete the screening form below
First Name
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Last Name
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Phone Number
Email Address
Gender
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Male
Female
Date of Birth
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What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Which category best describes you? (select all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Have you been diagnosed with non-small cell lung cancer?
Yes
No
Have you been told that surgery is not an option?
Yes
No
Have you received at least one previous line of standard frontline therapy for your cancer, including a PD-1 or PD-L1 targeting immune checkpoint inhibitor (such as Keytruda, Opdivo, Imfinzi, Tecentriq, Libtayo)?
Yes
No
Unsure
Are you able to carry out work of a light or sedentary nature, e.g., light housework or office work?
Yes
No
Are you currently receiving treatment for your lung cancer?
Yes
No
Have you received targeted therapy for EGFR, ALK, ROS1, BRAF V600E, NTRK1/2/3, METex14 skipping, RET, or HER2 mutations?
Yes
No
Unsure
What is the best time to reach you?
Morning
Afternoon
Evening
How do you prefer to be contacted?
Call
Email
Text
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