CCF Nutrition Guide Order Form Would you prefer the Nutrition & Cholangiocarcinoma book as a(Required) Paperback Book (available only in the United States) Digital Download Name(Required) First Last Address(Required) Street Address 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 PhoneEmail(Required) HiddenWhich of the following best represents your race/ethnicity? (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 Please select all that apply.Which of the following best represents your ethnicity?(Required) Hispanic or Latino Not Hispanic or Latino Please select all that apply.Which of the following best represents your 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 Please select all that apply.To which gender identity do you most identify?(Required) Male Female Transgender Male Transgender Female Gender variant/non-conforming Not listed Prefer Not to Answer What is the highest level of education the patient has completed?(Required) Less than high school Completed some high school High school graduate or equivalent (e.g., GED) Completed some college or technical school, but no degree Associates Degree or Technical school graduate College graduate (e.g., BA, AB, BS) Completed some graduate school, but no graduate degree Completed graduate school (e.g., MS, MD, Ph.D., PharmD) Prefer not to answer What is the patient’s current employment status?(Required) Employed - full-time Employed - part-time Receiving short or long-term disability from employer Retired Stay at home parent Student Unemployed and not seeking work Unemployed and receiving Social Security Disability Insurance Unemployed but looking for part or full-time work Not sure Not applicable Preferred not to answer Is there another language that you would prefer to see these materials in?(Required) Yes No Please specify the language(s) you would prefer Spanish Mandarin French Other Which other language(s) would you prefer? Are you a(Required) Patient Caregiver, answering for a patient Medical professional Other What was your age at diagnosis?(Required) What type of health insurance does the patient have?(Required) Do not have health insurance Insurance coverage through a current or former employer or spouse’s/partner’s employer Individual/Family insurance plan purchased directly by you Insurance coverage through my parent’s or legal guardian’s employer Medicaid (MediCal for California residents) Medicare Medicare Advantage Veterans Administration (VA)/CHAMPUS/TRICARE Not sure Not applicable Preferred not to answer What is your total annual household income before taxes? (Please include money earned by you, your spouse/partner, and any other adult in the household. Please give us your best estimate if you’re not sure.)(Required) Less than $15,000 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $124,999 $125,000 to $149,999 $150,000 to $199,999 $200,000 or over Not sure Not applicable Prefer not to answer Was the patient able to have surgery/transplant?(Required) Yes, part of the patient’s liver was resected Yes, the patient had a liver transplant Yes, the patient had Whipple procedure No, surgery was not an option When was the date of initial diagnosis?Month(Required)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear(Required)202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000Before 2000HiddenWhen was the date of initial diagnosis? (mm/yy)At the time of diagnosis, what was the cancer stage?(Required) Early-stage (tumor can be removed by surgery) Advanced stage (tumor can’t be removed by surgery due to spread to adjacent organ but has not spread into other distant body organs) Metastatic (tumor spread to other distant body organs) What is the patient’s diagnosis?(Required) 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 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 Other diagnosis Has the patient’s cancer tissue and/or blood sample been submitted for biomarker testing?(Required) Yes No Not sure Does the patient know their mutations?(Required) Yes No Please indicate which mutation ALK ATM ARID1A BRAF BRCA1/2 CDKN2A EGFR FGFR2 HER2/ERBB2 IDH1 IDH2 KRAS MDM2 MET NOTCH1 NRG1 NTRK PI3KCA RET ROS1 High tumor mutational burden Microsatelite instability (MSI) PD-L1 positive Other Other mutation Is the patient currently receiving any cancer treatment?(Required) Yes No Not sure Not applicable If “Yes” what type of treatment has the patient received? (Select all that apply) Surgical resection [only part of my liver was resected] Liver transplantation Whipple procedure Chemotherapy Targeted therapy Immunotherapy Local therapy [e.g., Radiofrequency ablation, Transarterial chemoembolization (TACE), Trans-arterial radioembolization (TARE, commonly referred to as Y90), bland embolization, Cryoablation, Ethanol ablation, Microwave ablation] Radiation therapy [e.g., external beam radiation therapy using 3-Dimensional Radiation Therapy, IMRT, Proton therapy,..etc. or internal beam radiation therapy which is known as brachytherapy] Clinical trial Stent placement IV nutrition Enteral nutrition Palliative therapy Not sure Other Other treatments Did the patient change their diet, by personal choice, after being diagnosed?(Required) Yes No In what way did the patient change their diet? Select all that apply Keto diet Low Carb diet Intermittent fasting FODMAP Mediterranean diet Paleo diet Carnivore diet Vegetarian diet Vegan diet Other Other diet change Was the patient referred to a nutritionist/dietician?(Required) Yes No Did the patient see or are they currently seeing a nutritionist/dietitian?(Required) Yes No Did the patient change their diet after seeing a nutritionist/dietician?(Required) Yes No In what way did the patient change their diet? Select all that apply Keto diet Low Carb diet Intermittent fasting FODMAP Mediterranean diet Paleo diet Carnivore diet Vegetarian diet Vegan diet Other Other diet change How does the patient’s current mental health or mood affect their nutritional habits?(Required) Anxiety/depression causes the patient to eat more Anxiety/depression causes the patient to eat less Anxiety/depression does not affect the patient’s nutritional habits How did the patient learn about this resource? Select all that apply(Required) CCF website or staff Internet search Physician Oncology Nurse/Nurse Practitioner Friend Family Member Fellow patient Integrative oncology team Dietician/Nutritionist Cancer Librarian Social Media Other Other Title(Required) Institution(Required) What is your specialty?(Required) Medical Oncologist Radiation Oncologist Surgical Oncologist Gastroenterologist/hepatologist Primary care physician Nurse Practitioner Physician Assistant Dietician Nutritionist Other Other specialty How will you use this resource?(Required) Encourage patient to order Personal education Other Do you regularly refer your cholangiocarcinoma patients to a Nutritionist/Dietician?(Required) Yes No Can we send you additional resources for your patients?(Required) Yes No Please indicate your profession(Required) Can we send you additional resources for your cholangiocarcinoma patients?(Required) Yes No