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Are you a...(Required)PatientCaregiverContact InformationPlease provide the patient's contact informationName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)Would the patient like to receive text messages from the Cholangiocarcinoma Foundation?(Required)YesNoHow did the patient hear about the Cholangiocarcinoma Foundation?(Required) Search engine (Google, Yahoo, etc.) Facebook Twitter LinkedIn Instagram Physician Referral Family Member/Friend Other When was the patient diagnosed with cholangiocarcinoma?Month(Required)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear(Required)2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000earlier than 2000Hidden(No longer active) What type of cholangiocarcinoma was the patient diagnosed with? Intrahepatic Cholangiocarcinoma [cancer occurs inside the liver where cancer develops in the hepatic bile ducts or the smaller intrahepatic biliary ducts] Perihilar Cholangiocarcinoma or Hilar (Klatskin Tumors) [a type of extrahepatic cholangiocarcinoma where cancer develops where the right and left hepatic ducts have joined and are leaving the liver] Distal Extrahepatic Cholangiocarcinoma [a type of extrahepatic cholangiocarcinoma where cancer occurs outside the liver after the right and left hepatic bile ducts have joined to form the common bile duct. This type of cancer is found where the common bile duct passes through the pancreas and into the small intestine] Not sure Other What type of cholangiocarcinoma was the patient diagnosed with?(Required) Intrahepatic Extrahepatic Perihilar Extrahepatic Distal Combined HCC and CCA Gallbladder CUP - Cancer of Unknown Primary HiddenWhich race/ethnicity best describes the patient? (OLD) Asian or Asian American Black or African American Hispanic, Latinx, or Spanish origin Native American or Alaska Native Native Hawaiian or other Pacific Islander White Non-Hispanic Don’t know Prefer not to answer Prefer to self describe Which of the following best represents the patient's ethnicity?(Required) Hispanic or Latino Not Hispanic or Latino Which of the following best represents the patient's race?(Required) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Some other race Prefer not to answer Self described ethnicity To what degree do you agree or disagree with the following: The patient was provided with treatment options by their doctor/medical team(Required)Strongly DisagreeSomewhat DisagreeNeither Agree or DisagreeSomewhat AgreeStrongly AgreeNot ApplicableTo what degree do you agree or disagree with the following: The patient and/or caregiver understood the treatment options provided by the patient's doctor(Required)Strongly DisagreeSomewhat DisagreeNeither Agree or DisagreeSomewhat AgreeStrongly AgreeNot ApplicableWas the patient encouraged to receive a second opinion?(Required)YesNoUnsureTo what degree do you agree or disagree with the following: The patient and/or caregiver was provided with information on biomarker testing, also known as molecular profiling, genomic testing, or NGS testing?(Required)Strongly DisagreeSomewhat DisagreeNeither Agree or DisagreeSomewhat AgreeStrongly AgreeNot Applicable(please view the above biomarker video for more information)Was biomarker testing done?(Required)YesNoIf no, why? Insurance did not cover Too expensive Not enough tissue Doctor did not recommend Other To what degree do you agree or disagree with the following: The patient and/or caregiver was provided with information on clinical trials by the patient’s doctor/medical team(Required)Strongly DisagreeSomewhat DisagreeNeither Agree or DisagreeSomewhat AgreeStrongly AgreeNot ApplicableWas a clinical trial offered as a first-line treatment for this cancer? (First-line treatment is defined as the first treatment received)(Required)YesNoNot ApplicableHow would the patient and/or caregiver currently rate their anxiety as pertaining to the diagnosis?(Required)No anxietyLow level of anxietyModerate level of anxietySevere level of anxietyPrefer not to answerTo what degree does the patient and/or caregiver feel they have access to emotional support for the disease?(Required)No access to emotional supportSome access to emotional supportFull access to emotional supportPrefer not to answerTo what degree do you agree or disagree with the following: The patient and/or caregiver is able to advocate for the patient’s medical needs(Required)Strongly DisagreeSomewhat DisagreeNeither Agree or DisagreeSomewhat AgreeStrongly AgreeNot ApplicableHas the patient and/or caregiver actively sought information about the diagnosis outside of their doctor/care team?(Required)YesNoWhat information did the patient/caregiver obtain and what was the source? (if known)Would the patient and/or caregiver like the Patient Advocates at the Cholangiocarcinoma Foundation to contact them?(Required)YesNo[Patient Advocates can help assist with resources, clinical trial information, and providing emotional support, among other things] Get more resources and support from the Newly Diagnosed/New to CCF program.