Return to Wellness
Eligibility Survey
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Ethnicity
Age
Occupation
Emergency Contact Name:
Emergency Contact Phone Number:
Relationship Status
Single
Married
Separated/ Divorced
Partnered
Widowed
How did you hear about this program? (You may select more than one option)
Primary Care Provider
Oncologist
Surgeon
Nurse or office staff
Social Worker
OB/Gyn
Other care provider
Internet Search/ Website
Newspaper
Health Fair
Friend or Family
CSC Calendar
CSC Staff
Advertisement
Social Media
Other
If you were referred by a healthcare provider, with which medical system is that person affiliated?
Please Select
Huntington Health
City of Hope
USC
UCLA
Providence Medical Group
PIH Health
Kaiser Permanente
Other
Is this the first time you have come to a CSC Greater San Gabriel Valley program?
Yes
No
What type of treatment did you have? (Select all that apply)
Lumpectomy
Mastectomy
Chemotherapy
Radiation
Other
If you had a mastectomy, did you have reconstruction? If so, what type?
When did you complete active treatment for breast cancer (e.g. surgery, chemotherapy, and/or radiation therapy)?
-
Month
-
Day
Year
Date
Are you continuing treatment with any of the following? (You may select more than one option)
Hormone suppressant therapy (Tamoxifen or aromatase inhibitors)
Targeted therapy (Herceptin)
Other
What stage was your breast cancer when you were originally diagnosed?
Stage 0
Stage 1
Stage 2
Stage 3
Don't know/ unsure
What is the current state of your cancer?
No evidence of disease
In remission
Cancer free
What types of physical activity do you currently participate in?
What do you hope to gain by participating in this program? (check all that apply)
Expand social support and make new friends
Increase self-confidence and sense of control
Improve physical strength, endurance, and flexibility
Reduce fatigue and feel more energetic
Reduce fear and anxiety
Reduce symptoms of depression
Learn about nutrition
Sleep better
Lose weight
Feel better about my body
Find peace and spirituality
Better manage long-term side effects from treatment
Other
On a scale of 0 - 10, with 0 being the lowest and 10 being the highest, please indicate how anxious you feel right now:
Comments about feelings of anxiety:
On a scale of 0 - 10, with 0 being the lowest and 10 being the highest, please indicate how confident you feel about knowing how to monitor your health after breast cancer:
Comments about your feelings of confidence about monitoring your health:
Thank you for completing this survey! A member of our team will reach out to you soon to follow up.
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