Language Undefined Welcome to BMT InfoNet’s CAR T Therapy community. We are gathering information to learn more about those who had or are considering CAR T Therapy. This information will help us understand more about you and what your needs are so that we can best meet them. Please complete the form or call our office at 888-597-7674. CAR T Therapy Patient/Suvivor/Family/Friend First Name Last Name Email - Home Birth Year Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Relationship to Patient - None -Patient/SurvivorSpouse of Patient/SurvivorPartner of Patient/SurvivorChild of Patient/SurvivorParent of Patient/SurvivorSibling of Patient/SurvivorGrandparent of Patient/SurvivorOther Relative of Patient/SurvivorUnrelated Caregiver of SurvivorDonorFriendOtherUnknown Please select the disease from the drop down - None -Acquired Pure Red Cell AplasiaAcute Lymphoblastic Leukemia (ALL)Acute Mast CellAcute Myeloid/Myelogenous Leukemia (AML)Adrenoleukodystrophy (ALD)AmyloidosisAtaxis TelangiectasisAutoimmune Hemolytic Anemia (AIHA)Autoimmune Lymphoproliferative Syndrome (ALP)Autoimmune Thrombocytopenic PurpuraB-cell Prolymphocytic Leukemia (B-PLL)Bare Lymphocyte SyndromeBattens DiseaseBehcet's DiseaseBiphenotypic acute leukemia (BAL)Blastic plasmacytoid dendritic cell neoplasm (BPDCN)Bone-Marrow FailureBrain TumorBreast CancerBurkitt's LymphomaCastlemans DiseaseCd 40 Ligand DeficiencyCentral Nervous System MalignanciesChediak-Higashi SyndromeChronic Eosinophilic Leukemia (CEL)Chronic Granulomatous DiseaseChronic Inflammatory Demyelinating Polyneuropathy (CIDP)Chronic Lymphocytic Leukemia (CLL)Chronic Myeloid (Myelogenous) Leukemia (CML)Chronic Myelomonocytic Leukemia (CMML)Chronic Neutrophilic Leukemia (CNL)Colon CancerCongenital Amegakaryocytic Thrombocytopenia (CAMT)Cutaneous T-Cell Lymphoma (CTCL)Devic's disease- Neuromyelitis optica (NMO)Diamond-Blackfan AnemiaDiGeorge AnomalyDyskeratosis CongenitaEssential Thrombocythemia (ET)Evan's SyndromeEwing's SarcomaExperience with All Diseases treated by transplantFanconi anemia (FA)Felty's SyndromeGATA2 DeficiencyGauchers DiseaseGerm Cell TumorHairy Cell LeukemiaHistiocytosis, Hemophagocytic (HLH)Histiocytosis, Langerhans Cell (LCH)Hodgkin's Disease (HD)Hunter's DiseaseHurler's SyndromeHyper IgE SyndromeI-Cell diseaseIdiopathic Thrombocytopenic purpura (ITP)Immunodysregulation Polyendocrinopathy enteropathy X-linked Syndrome (IPEX)Juvenile Chronic Granulocytic (JCGL)Juvenile Myelomonocytic Leukemia (JMML)Kostmann's SyndromeKrabbe DiseaseLarge Granular Lymphocytic LeukemiaLesch-Nyhan diseaseLeukemiaLeukocyte Adhesion DeficiencyLight Chain Deposition DiseaseLung CancerLupus, SystemicLymphomatoid GranulomatosisMantle Cell Lymphoma (MCL)Maroteaux-Lamy SyndromeMelanomaMetachromatic LeukodystrophyMorquioMucopolysaccharidosis type 1 (MPS 1)Multiple MyelomaMultiple SclerosisMyelodysplastic Syndrome (MDS)Myelofibrosis (MF)Myeloid sarcomaMyeloproliferative Disorder/Neoplasms (MPD)(MPN)Natowicz SyndromeNeuroblastomaNiemann-Pick DiseaseNon-Hodgkin Lymphoma (NHL)Omenn SyndromeOsteogeneic SarcomaOsteopetrosisOvarian CancerParkinson's DiseaseParoxysmal Nocturnal Hemoglobinuria (PNH)Poems SyndromePolycythemia Vera (PV)PorphyriaPrimitive Neuroectodermal Tumor (PNET)Pure red cell aplasiaRenal Cell CancerRetinoblastomaRheumatoid Arthritis (RA)Sanfilippo SyndromeSchwachmann-Diamond SyndromeSclerodermaSevere aplastic anemiaSevere Combined Immunodeficiency Disease (SCID)Sezery SyndromeSickle Cell DiseaseSoft Tissue SarcomaT-Cell Prolymphocytic leukemia (T-PLL)Testicular CancerThalassemiaThymomaWaldenstrom's MacroglobulinemiaWilm's TumorWiskott-Aldrich SyndromeWolman DiseaseX-Linked AgammaglobulinemiaX-Linked Hyper IgM SyndromeX-Linked Lymphoproliferative Syndrome (XPL)Other Disease CAR T-cell therapy Did the Patient have CAR T Therapy * - Select -YesNoConsidering CAR-T Date of CAR-T Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071 Possible Date on Considering CAR T-Cell Therapy Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071 Patient Age at time of CAR-T CAR-T Type - None -CAR-T Auto (using own t-cells)CAR-T Allo (using donor t-cells) CAR-T Therapy - None -KymriahYescartaIde-cel/AbecmaTecartus®Other type of CAR-T TherapyUnknown Other Type of CAR-T Therapy Was CAR T part of a clinical trial - None -YesNo Center where CAR-T was done Health Issues after CAR-T Cytokine release syndrome Neurological problems Low White Blood Cell count Low red blood cell count (anemia) Other health issues after CAR-T Please describe health after CAR T Therapy Leave this field blank Submit
