The month of October is Brest cancer awareness month!

This October has been designated as "Brest Cancer awareness month" in Missouri, and to that end I am including a form from the State to report any incidence you may have personally encountered.

My wife, Linda is a survivor, and we have many more here in Ward 2, and Ward 1. If we fill these out and get them to the right people we may find out where this is coming from, and work on a remedy.

Cancer Patient Information Form
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
CANCER PATIENT INFORMATION FORM CI -
This form is being given to you as the first step in exploring a possible excess of cancer in your community. The person that gave it to you will explain the nature of the concern. The fact that you were given this form does not mean that there is a known problem causing cancer in your community. It simply means that the person who gave it to you would like the Missouri Department of Health and Senior Services (DHSS) to look at information from those with cancer in the community to determine if there may be a problem. Your information will be kept confidential, and will not be shared with the person who gave you the form. For questions about the process please call (573) 522-2840.


Please print and fill in all of the information as completely as possible for you, if you are the individual with cancer, or for your family member who had cancer but is no longer living. At a minimum include legal name, birthday, social security number, how long you lived in the area (community being investigated), and where you were diagnosed with cancer. This information allows the DHSS to confirm the information and use it to look into the concern. Write on the blank portion or the back of the form as needed.

Legal Name (Last Name, First Name, Middle Initial)
 Male  Female Social Security Number - - 
Current Address City / State / Zip
Phone Number ()- 
Birth Date (mm/dd/yyyy) // Death Date (mm/dd/yyyy)/  / 
Type of Cancer: Date of Diagnosis (mm/dd/yyyy) //
Address at Time of Diagnosis
(address, city, state, and zip)
Physician’s Name Facility name where you (or your family member) were first diagnosed with cancer. (Hospital or other facility)
Address when environmental exposure may have occurred (include street, city, state and zip) (For example, the address where you or your family member lived as a teen.)
Number of years you or your family member lived at the address where exposure may have occurred 
Do you currently smoke?Yes No If you don’t smoke now, what year did you quit smoking?
Did you ever smoke? Yes No How long did you smoke? years
Additional Information & Comments: Please feel free to provide additional information in this section or on the back. For example, maiden names, previous names used, if any. Information about your or your family member’s occupation, exposure, etc.)



Please return within 6 weeks of receipt to:
Bureau of Cancer and Chronic Disease Control, Cancer Inquiry Program
Missouri Department of Health & Senior Services
P. O. Box 570, Jefferson City MO 65102-0570 OR via fax (573) 522-2899

Please print out the form, fill it out, and send it to Jeff City. Keep a copy on file at your home for further.

Tom Ford

No. 222