The following questionnaire is provided for your convenience in identifying your particular type of Myeloma; your treatments to date; your health care providers; your caregiver; your medications and your reactions to those meds.  It will also help you to plan your future treatments and options.  You may need the help of your oncology team to answer the questions.  

We have developed a new program on our protected web site called NTMSG INTERACTIVE.  The North Texas Myeloma Support Group uses these questionnaires, with the permission of each member, to record information on treatments and problems they have experienced with Multiple Myeloma. We can then access this information in this program, find others in the group with similar situations, ask questions and make informed decisions as we proceed with our own treatment plans.

If you would like to participate in NTMSG INTERACTIVE, please indicate your willingness to do so by signing the bottom of the completed questionnaire.  It is available on our protected web site: http://northtexas.myeloma.org/newsletters.html. You can fill it in there, make copies, or forward it from the web site to Rex Siefert at:  rexandlinda@comcast.net. A signed copy can be faxed to Marcia Sawyer at 972 359-7509, or mailed to her at 8305 Novaro Drive, Plano, TX 75025

This is an exiting new opportunity we have to help each other as we  “SHARE THE HOPE!”

Thank you,

 NTMSG

 Date:    How Did You Hear About Our Group?

 Patient     M  F   Age DOB //

 Address

 Phone      Email Address

 Occupation

 Caregiver Name

 Cregiver RelationshipSpouse  Child Parent Other

 Address:   Same    Other

 Phone:      Same  Other   E mail address Same Other

 When were you diagnosed?

 What were your symptoms?Anemia  Tiredness  Weakness  Bone Pain  

 Location of pain

 Other symptoms

 What type of doctor did you see first?

 What was your diagnosis before MM?

 What treatment did you receive prior to diagnosis?

 Who is your oncologist?   Location

 Type of myeloma?    IGG                    IGA                         IGD                   

                               IGE                    Non-Secretory           Smoldering     

                               MGUS               Kappa Light-Chain     Lambda Light-Chain 

                             Other

 Durie/Salmon Staging at diagnosis Stage 1    Stage 2    Stage 3       

 Kidney Involvement? Yes   No

 Have you had a bone marrow biopsy and aspiration?  Yes  No   How many?

 M-spike or protein count(concentration) at diagnosis?     Now?

Protein count found:      in the blood(serum)  Amount

                                   urine(24 hour urine catch)  Amount

                                   non-secretory

Have you had a bone survey by 

     X-ray (#)                    MRI (#) 

     CT Scan (#)               MIBI (# )

     PET Scan (Fdg) (#)    Bone Density Test (# )

     Other

Blood counts

Have you had problems with your White Count    Red Count    Platelets

Have you had?   Neupogen           How Long?  Dose?  

                         Procrit(Epogen)   How Long?  Dose?  

                         Other                  How Long?  Dose?  Drug Name  

Bones

Do you have any known plasmacytomas?Yes  No   Body Location

Treatment?Radiation (# ) Surgery (# )   Other

Any known lesions?    Yes  No   Body Location

Any known fractures? Yes  No   Body Location

Collapsed vertebrae?   Yes  No   How many?   Where? (vertebrae alpha numeric)

Treatment(s)        Back Brace                    Radiation (# )

                           Injections (# )     Vertebraplasty     

                           Kyphoplasty    Doctor

Are you now or have you takenBisphosphonates? Yes No

If yes 

Aredia Dosage    mgs. for  hours

Zometa Dosage    mgs. for  minutes

If yes but you stopped the treatment, why? Kidney Rest  Other

How long were you treated?

Infections/Other diseases

Have you had any serious infections?Bronchitis (#) Pneumonia (#) Sinus (# )

Other

Have you had problems with    Kidneys    Liver    Heart Lungs    Diabetes    Neuropathy

                                              High Blood Pressure   Other
Treatment for any of the above:

Other forms of cancer:   Have now (type)  Have had (type)   

Treatment for current/previous cancer other than myeloma:

Previous

Current

Are you taking chemotherapy at this time?  Yes   No              Previously?Yes   No

Taking now       Taken Previously

                                 Alkeran (melphalan)    Dosage     How long?

                              Prednisone                   Dosage    How long?

                              Cytoxin                        Dosage       How long?

                              Dexomethosone           Dosage      How long?

                              VAD                           Dosage     How long?

                              BLT                            Dosage      How long?

                              Thalidomide                 Dosage       How long?

                              Other   Dosage      How long?

Have you had a transplant(s) to treat Myeloma?    Yes    No

Type of transplant      Peripheral Blood Stem-cell Transplant (PBST)-Autologous

 Donor  transplant-Allogenic

Are you considering a transplant? Yes    No                       When?  

If considering a transplant, which are you considering?  (check all that apply)

 PBST Single  Donor  bone marrow PBST TandemDonor stem cell  Mini-allogenic

Peripheral Blood Stem-cell Transplant (PBST)

When and where was your stem cell collection

When was your stem cell infusion (PBST)?

Was this a single or double transplant?     Single Double

Hospital  Transplant doctor

What was your high dose chemo in preparation?

Did you have total body radiation (TBI) prior to transplant?

Did you have any serious complications?

Donor Transplant

Type:  Donor bone marrow    Donor stem cell     Mini-allo  Donor’s relationship

Hospital                Doctor

What was your high dose chemo in preparation?

Did you have total body radiation (TBI) prior to transplant?

Did you have any serious complications?

Have you been to any of the major cancer centers for consultation?

 MD Anderson    Little Rock  Cedars Sinai