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Member Name
First Name
Last Name
Spouse's (or Significant Other's) First Name
Address 1
Street Address
Address Line 2
City
State (or Non-US)
- Select a value -
Non-US
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Spain
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Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Trinidad and Tobago
Turkey
Uganda
Ukraine
United Arab Emirates
UK (United Kingdom)
Uzbekistan
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
OTHER
Country (if Other)
Address 2
Street Address
Address Line 2
City
Region/Province/Territory
Postal / Zip Code
State (or Non-US)
- None -
Non-US
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
Country
- None -
Afghanistan
Algeria
Argentina
Australia
Austria
Bahamas
Bangladesh
Belgium
Belize
Bolivia
Brazil
Bulgaria
Burma
Canada
Chile
China
Colombia
Congo, Dem. Rep.
Costa Rica
Croatia
Cuba
Czech Republic
Denmark
Dominican Republic
Ecuador
Egypt
El Salvador
Ethiopia
Fiji
Finland
France
Germany
Ghana
Greece
Guatemala
Haiti
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Kenya
Lebanon
Malaysia
Mexico
Morocco
Mozambique
Nepal
Netherlands
New Zealand
Nicaragua
Nigeria
North Korea
Norway
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Romania
Russia
Saudi Arabia
Singapore
South Africa
South Korea
Spain
Sudan
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Trinidad and Tobago
Turkey
Uganda
Ukraine
United Arab Emirates
UK (United Kingdom)
USA (United States of America)
Uzbekistan
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
OTHER
Country (if Other)
Phone 1
Type
N/A
Home
Work
Winter
Summer
Area Code
Number
Ext.
Phone 2
Type
- None -
Home
Work
Winter
Summer
Area Code
Number
Ext.
Cell Phone
Area Code
Number
Medical History
Before Proton Therapy, have you ever been treated for prostate cancer?
Yes
No
If "Yes", please specify treatment method
- None -
Surgery
Brachytherapy
External Radiation
Cryosurgery
Other
Proton Therapy Information (check all that apply)
Proton
Photon
Hormones
Other
If other, please specify
Are you receiving the standard treatment protocol?
Yes
No
If "No," please specify your treatment protocol:
- None -
Shortened/Hypofractionation (20-26 treatments)
Shortened/SBRT (5 treatments)
Treatment End Date (Month)
- Select a value -
January
February
March
April
May
June
July
August
September
October
November
December
Estimate if you aren’t sure
Treatment End Date (Year)
- Select a value -
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Estimate if you aren’t sure
Age When Treated
Highest PSA (before treatment)
Estimate if you aren’t sure
Most Recent PSA (after treatment ended)
Enter a number here only if you have completed treatment.
Most Recent PSA Date Month (after treatment ended)
- None -
January
February
March
April
May
June
July
August
September
October
November
December
Most Recent PSA Date Year (after treatment ended)
- None -
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Gleason Score
Don't Know
3
4
4/5
5
5/6
6
6/7
7
7/8
8
8/9
9
9/10
10
T-Score (eg. T1a, T2b, etc.)
Was there a detectable tumor by DRE (Digital Rectal Exam)?
- Select a value -
Yes
No
Primary Medical Insurance (At Time of Treatment)
Enter "none" if you do not have insurance or are having problems with insurance.
Secondary Medical Insurance (At Time of Treatment)
Having problems with insurance?
- None -
No
Yes
Depending on the issue, we may be able to offer advice.
Where did (will) you receive proton therapy?
- Select a value -
Atlanta, GA
Baltimore, MD
Birmingham, AL
Bloomington, IN
Boston, MA
Cincinnati, OH
Cleveland, OH
Columbus, OH (James OSU)
Delray Beach, FL
Dresden, Germany
Falls Church, VA
Flint, MI
Franklin, TN
Fukushima, Japan
Groningen, Netherlands
Hampton, VA
Heidelberg, Germany
Houston, TX
Irving, TX
Jacksonville, FL (Ackerman)
Jacksonville, FL (Univ. of FL.)
Kansas City, KS
Knoxville, TN
Lancaster, PA
Little Rock, AR
Loma Linda, CA
London, UK (Proton International)
Miami, FL (BAPTIST)
Miami, FL (Sylvester)
Munich, Germany
New Brunswick, NJ
New York, NY
Oklahoma City, OK (Oklahoma Proton)
Oklahoma City, OK (Stephenson Proton Center)
Orlando, FL
Other
Philadelphia, PA
Phoenix, AZ
Prague, Czech Republic
Rochester, MN
Royal Oak, MI
Salt Lake City, UT (Huntsman Cancer Center)
San Diego, CA (CA Protons)
San Diego, CA (Scripps)
Seattle, WA
Seoul, South Korea
Shreveport, LA
Somerset, NJ
St. Louis, MO
Voorhees, NJ
Warrenville, IL
Washington, DC (Johns Hopkins)
Washington, DC (Medstar)
If other, please specify
Referral Source
Important: Please provide the name(s) of individual(s) who informed you about proton therapy and/or former proton therapy patients you communicated with prior to making your treatment decision. If you don't remember name(s), enter "Forget." If you learned about proton therapy on your own, enter "Self."
What is/was your profession?
Retired?
- None -
Yes
No
Are you willing to share your experience with non-members?
Yes
No
Would it be O.K. for BOB to use the information you provided on this registration form in order to be able to assist individuals (non-members) who are evaluating proton therapy and would like to speak with someone with similar conditions as theirs?
By selecting ‘No’, your information will not be shared by BOB with non-members who are evaluating proton therapy. However, your information will still be used by BOB to enable communication between BOB members. If you do not want your information to be shared with anyone please do not register as a member.
Giving Back Participation
Yes, sign me up!
No, I do not wish to hear about research efforts and funding needs or participate in the program mentioned above
Periodically we share information with BOB members about proton research and other programs underway at Loma Linda University Health. If you do not wish to hear about these programs or participate in supporting them please let us know by checking the corresponding box below.
Attestation
Accept Terms & Conditions of Use
Do Not Accept
By selecting the ‘Accept’ button below, I acknowledge that I am voluntarily applying for membership at the Brotherhood of the Balloon (BOB) prostate cancer support group and providing my personal information to be used according to BOB’s Terms and Conditions of Use Policy. I understand that my application will be reviewed and that I may be contacted for additional clarification prior being accepted as a member. I understand that as a member, I may become aware of other members’ personal information and will treat that information with care and will not share it with anyone else unless the owner of the information specifically authorizes me to do so. I understand that the information I have provided on this registration form may be shared with other BOB members according to the Terms and Conditions of Use Policy. I also agree to make myself available to be contacted by other BOB members in order to share my personal experience with proton therapy. I further understand that any disclosure of information carries with it the potential for an unauthorized redisclosure, therefore it is up to me to decide what additional personal information I want to share with other BOB members when contacted by them.