Hampton Roads Virginia
Carcinoid-Neuroendocrine Cancer Group
Membership Form
An informative educational support group for carcinoid and other neuroendocrine patients, family, friends,
Physicians, physicians assistants, nurses, lab and imaging specialists, medical staff members, and other medically related professionals
Join patients, sentara healthcare, sentara healthcare physicians, and Dr. A.I. Vinik, a renowned carcinoid and endocrine specialist, as we learn about carcinoid cancer, carcinoid cancer syndrome andother endocrine tumors. Together we can learn how these cancers are diagnosed, monitored, different treatment options, andfor patients, living with carcinoid cancer.
Hampton roads consists of Chesapeake, Hampton, Newport News, Norfolk, Suffolk, Poquoson, Portsmouth, Virginia Beach, and Williamsburg. Counties included are Gloucester, JamesCity, Surry, Isle of Wright, and Southampton. Other areas included are Richmond, and Bordering areas of North Carolina to the Outer Banks.
For additional information or membership forms, contact
sandi barkan at 757-456-5331 or Susan burke at 757-464-6042 or
Email :
Please sign-up for the elist digest available on yahoo groups
for up to date local information
www/health.groups.yahoo.com/group/AllHamptonRoadsVirginiaCarcinoidGroup
hampton roads virginia carcinoid-neuroendocrine cancer group Membership Application
member Information
Name:Date of birth: / Home Phone: / Mobile Phone:
Address:
City: / State: / ZIP Code:
Email: / How did you hear of the Hampton Roads Carcinoid-Neuroendocrine Group?
Membership details
(Please check) Patient Spouse/Significant Other/Partner Patient Family/Friend Physician Physician AsstMedical Imaging Tech Medical Laboratory RN/LPN Other Medical Staff Medical Industry
Mailing address if different from above
City: / State: / ZIP Code:
Contact Phone: / Contact E-mail: / Contact Fax:
Information Desired: (Please check)
All Information Meeting Notices Medical updates
Hobbies/Areas of Interest:
medical member information
Area(s) of expertise:Employer: / Employer Location:
Continuing Education Credits (CME/CEU) desired: (Please check) YES NO
Other professional memberships held:
patient spouse/significant other/partner/family/friend member information
Briefly state areas of interest/expertise where you would consider assisting the group:patient member Information
How your cancer was discovered: (Please check) Accidentally Routine Physical Surgery for another reasonOther, state how
When/where diagnosed: / Method: (Please check) Biopsy Lab Markers
Location(s) of primary(ies): / Type: (Please check)
Typical Atypical Unknown
Location(s) of mets: / Carcinoid Syndrome: (Please check) YES NO
Age when diagnosed: / Diagnosing Physician/area of expertise:
Traditional Chemo received: YES NO If yes, indicate what type(s), method(s), and frequency:
Sandostatin Treatment/Chemo: YES NO If yes, indicate what type(s), method(s), and frequency:
Surgeries and dates, list all:
Surgery performed: Date: Physician:
Surgery performed: Date: Physician:
Surgery performed: Date: Physician:
Surgery performed: Date: Physician:
Surgery performed: Date: Physician:
Current employment and title: / Former employment and title:
Current physicians / medical caregivers
Primary Care: Oncologist: Endocrinologist:
Gastroenterologist: Cardiologist: Heart Surgeon:
OB/GYN: Ophthalmologist: General Surgeon:
Allergist: Immune System: Periodonist:
Dentist: Dental Hygienist: Other:
Previous Possible Misdiagnoses and dates:
Have you been treated for other cancers:
(Please check) NO YES If yes, indicate type:
Symptoms prior to diagnosis: (Please check and indicate estimated date of onset)
_____Lower abdominal pain _____Upper abdominal pain _____Reflux: _____Diarrhea
_____Nocturnal bowel movements _____More frequent bowel movements _____Steatorrhea _____Appetite Loss
_____Weight loss greater than 10 lb _____ Weight gain greater than 10 lbs _____Night sweats _____ Day sweats
_____Flushing / redness chest _____Flushing / redness neck _____Flushing / redness face
_____Flushing / redness back, arms _____Asthma _____Wheezing _____Heart disease:
_____Eye related problems _____Thrush _____Dry mouth, skin, etc.
_____Repeated infections Other, please list:
Primary tumor secretions:
Work related stress levels 5 – 10 yrs preceding diagnoses:
low average high very high extremely high
Personal related stress levels 5 – 10 yrs preceding diagnoses:
low average high very high extremely high
The Hampton Roads Virginia Carcinoid-Neuroendocrine Cancer Group has been created by Patients with this and related cancers, Dr. A.I. Vinik of EVMS, an internationally renowned Carcinoid and Endocrine specialist, nationally acclaimed Sentara Healthcare, renowned Sentara Healthcare Physicians, related medical staffs, and medical professionals in the areas of imaging, laboratory, nutrition, disease management specialties to provide both support and information to the newly diagnosed patient and provide up to date educational information and related skills to the entire medical community from physicians to hospital staffs in all departments and medical office staff members.
Meetings for the 2005 summer months are as follows:
July 187:00 PM4625 Hagen Drive, Va.Beach, Va 23462
August 22 7:00 PM433 Cassleberry Lane, Va. Beach, Va. 23462
Beginning in the Fall of 2005, the Hampton Roads Virginia Carcinoid Group will hold a series of meetings addressing all issues regarding the diagnosis, treatment options, and quality of life issues regarding this cancer. Some of the topics are shown below:
Carcinoid heart disease
Improving diagnostic skills
Carcinoids and Nutrition
Carcinoid surgical risks vs benefits
Special imaging needs of patients with carcinoids and other NETs
Carcinoids, sandostatin, and digestive system changes
Carcinoid related diarrhea
Carcinoid cancer and weakened immune systems
Treatment options
Chemoembolization and carcinoids
Anesthesia and carcinoids
Carcinoid crisis
Carcinoid syndrome flushing and its control
Emotional effects of carciniod cancer and carcinoid syndrome
Carcinoid insurance issues
Carcinoid medical teams and how they impact the patient
These meetings are for the patient, patient supporter, and the medical community member.
For additional information or membership forms, contact
sandi barkan at 757-456-5331 or Susan burke at 757-464-6042 or
Email:
Please sign-up for the elist digest available on yahoo groups
for up to date local information
www/health.groups.yahoo.com/group/AllHamptonRoadsVirginiaCarcinoidGroup