Form Gravity

Enter the name of the healthcare professional you are addressing your letter to. (include the appropriate pre-fix IE Dr., Mr. Ms. etc.)

Please select the salutation that best fits the tone of the message you would like to send to your healthcare provider. You may also choose to write your own.

I have been thinking about my past and future health, and I realize I have some gaps in my knowledge.

I am preparing for our upcoming appointment, and one of the things I would like to talk with you about is my history of cancer and how I can stay healthy in the future.

I look forward to our upcoming appointment. I would like to work with you as I strive to be as healthy as possible.

I would like to write my own salutation message.

Other

Select your Diagnosis

Time since diagnosis

How old you where at time of diagnosis

Select your treatment

Bone marrow transplant

Chemotherapy

Hormone therapy

Immunotherapy

Radiation therapy

Surgery

Targeted biologic therapy

Has this treatment ended? If yes, please enter how long ago your treatment ended.

Yes

Did you get any other treatment for this diagnosis?

Bone marrow transplant

Chemotherapy

Hormone therapy

Immunotherapy

Radiation therapy

Surgery

Targeted biologic therapy

I did not get any other treatments

Has this treatment ended? If yes, please enter how long ago your treatment ended.

Yes

This next paragraph is for asking your provider questions. Please select the phrasing that best fits the prompt or question you would like to ask your healthcare provider. You may choose 1 of these options or write out your own using the 'other' option.

I would like to know more specific details about my cancer diagnosis and the treatments I received.

I am wondering how my past treatments may affect my future health.

I would like to know whether I need special tests (blood tests, other screening or surveillance) because of my cancer history.

I would like to know more specific details about my cancer diagnosis and the treatments I received. I am also wondering how my past treatments may affect my future health and if I need special tests (blood tests, other screening or surveillance) because of my cancer history.

I would like to write my own question(s).

Select the concluding paragraph that best fits your needs or use the other option to write your own.

I would like to meet with you to talk about these questions. Can we please schedule an appointment to discuss?

I would like to talk with you by phone about these questions. Can you please call me when you are available?

I look forward to talking with you about these questions at our upcoming appointment.

I would like to write my own concluding paragraph.

Select a closing line or write your own

Thank you for your help and support!

Thank you for your assistance!

Other

Optional: If you would like to share information about our Stanford Medicine online course for Primary Cary physicians caring for cancer survivors, please select yes below.

Yes, I would like to share the information with my Doctor.

No, I would not like to share the information with my Doctor.

Please review your entries carefully before sending your letter to yourself. There will not be an option to edit unless you have access to PDF editing software. You may be able to open the PDF file, select all, and paste the contents of your letter into a productivity software like Microsoft Word or Apple Pages; however, we can not guarantee this option or that the formatting will remain consistent. Once you click "submit", the data you entered is only available in the letter sent to the email you provided. Please double check that you have entered your email address correctly. We will not be able to retrieve any copies of your letter or the information you entered. This security is in place to protect your personal medical information.

I am ready to submit button then reveals the email entry and submit button.

I am not ready yet.

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