On what date were you first diagnosed with mesothelioma?If you don't know the exact date, please take your best guess. What type of mesothelioma do you have?*Pleural (Malignant Pleural Mesothelioma)PeritonealPericardialTesticularI don't knowDo you know the cell-type or histology?*EpithelialSarcomatoidBiphasic (mixed epithelial and sarcomatoid)I don't knowAre you CURRENTLY a candidate for mesothelioma surgery?*YesNoI don't know Are you planning to have mesothelioma surgery?*Planned types of surgery may include: 1. Extrapleural Pneumonectomy 2. Pneumonectomy 3. PleurectomyYesNoI don't knowAs a surgical candidate, have you received any kind of prior treatment for mesothelioma?*YesNoI don't know As a surgical candidate, have you had chemotherapy for mesothelioma?*YesNoI don't know Have you received any kind of treatment for mesothelioma?*YesNoI don't know Was standard or standard-of-care chemotherapy refused?*YesNoI don't know How many different types of chemotherapy have you had?*Another way this question may be worded would be to ask: "How many different lines of chemotherapy have you had?"One (1)Two (2)Three (3)Four or more (4+)I don't know Was standard or standard-of-care chemotherapy refused?*YesNoI don't know Are you still receiving chemotherapy for mesothelioma?*Yes, I still have at least one chemotherapy appointment remainingNo, I have completed or stopped receiving chemotherapyI don't knowWhat was the approximate date of your last chemotherapy treatment?* What was the 1st or 1st-line of chemotherapy used?*The two most common would be: Pemetrexed (Alimta) and Cisplatin or Pemetrexed (Alimta) and Carboplatinpemetrexed/cisplatin (combination)pemetrexed/carboplatin (combination)pemetrxed/cisplatin/bevacizumab (combination)gemcitabine/cisplatin (combination)carboplatin (alone)cisplatin (alone)gemcitabine (alone)pemetrexed (alone)vinorelbine (alone)I don't know What was the 2nd or 2nd-line of chemotherapy used?*pemetrexed/cisplatin (combination)pemetrexed/carboplatin (combination)pemetrxed/cisplatin/bevacizumab (combination)gemcitabine/cisplatin (combination)carboplatin (alone)cisplatin (alone)gemcitabine (alone)pemetrexed (alone)vinorelbine (alone)I don't know What was the 3rd or 3rd-line of chemotherapy used?*pemetrexed/cisplatin (combination)pemetrexed/carboplatin (combination)pemetrxed/cisplatin/bevacizumab (combination)gemcitabine/cisplatin (combination)carboplatin (alone)cisplatin (alone)gemcitabine (alone)pemetrexed (alone)vinorelbine (alone)I don't know What was the 4th or 4th-line of chemotherapy used?*pemetrexed/cisplatin (combination)pemetrexed/carboplatin (combination)pemetrxed/cisplatin/bevacizumab (combination)gemcitabine/cisplatin (combination)carboplatin (alone)cisplatin (alone)gemcitabine (alone)pemetrexed (alone)vinorelbine (alone)I don't know What were the results of your last Scan or PET Scan?*Please answer this question based on the results of the last scan done. We recognize that you may have another scan scheduled or may be awaiting the results of a recent scan.There was less mesothelioma than the prior scanThere was no progression since the prior scan (stable)The mesothelioma had progressedI don't know Which of the following would best describe you?*I am:Fully active, able to carry on all pre-disease performance without restrictionRestricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office workAmbulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hoursCapable of only limited selfcare, confined to bed or chair more than 50% of waking hoursCompletely disabled. Cannot carry on any selfcare. Totally confined to bed or chairI don't know
