The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

LWy6CrU4z64sTgpjDVYDowmeFnd5JaSMbAJCHXeQ5SaZ8ReUgVTW56RwtzxTiktYfb

CRUSH!!MDS Patient Questionnaire

Hello! Thank you for your interest in the "Predicting Response to Your MDS Treatment" study! Please fill out the questionnaire below. After you submit your answers, you will receive an email confirmation and a member of the team will be in touch with you shortly.

First Name

* must provide value

Last Name

* must provide value

Date of birth

M-D-Y

Age

Gender

Female

Male

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Street Address

City, State, Zip Code

Phone number

E-mail

* must provide value

Diagnosis

* must provide value

Myelodysplastic Syndrome (MDS)

Chronic Myelomonocytic Leukemia (CMML)

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Date of Diagnosis

M-D-Y

Have you been treated with Azacitidine?

* must provide value

Yes

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Please enter the dates of your Azacitidine treatment here (to the best of your knowledge):

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Have you been treated with Decitabine?

* must provide value

Yes

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Please enter the dates of your Decitabine treatment here (to the best of your knowledge):

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Please list any other treatment you have received for MDS or CMML here:

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Have you ever been treated for another cancer(s)?

* must provide value

Yes

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Please specify the type of cancer(s):

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Please list any treatments you received with corresponding dates (to the best of your knowledge):

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Doctor's Name

Doctor's Telephone Number

Please click on the "+ Add Signature" link and draw your signature. By providing your signature, you authorize the release of information from your medical record to a representative of Weill Cornell Medical College.

**Note: No physician or institution may give confidential information without the consent of the patient. If the patient is a minor, the consent form must be signed by the Parent or Legal Guardian and Should be Witnessed.**

* must provide value

Add signature

Comments

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