Cancer Health_Winter_2022

Quality of Life
Side effects from cancer or its treatment can diminish one’s quality of life. Please take our survey and let Cancer Health know which issues are affecting your everyday activities and general well-being.
What type(s) of cancer do you have? (Check all that apply.)

BladderBreastColorectalKidneyLeukemiaLungLymphomaMelanomaProstateOther
Are you currently receiving cancer treatment?

YesNo
On a scale of 1 to 5, rate how often you experience the following conditions. (1 = not at all, 5 = very often)

Anxiety

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Brain fog

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Constipation

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Depression

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Fatigue

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Mobility issues

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Nausea

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Pain

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Trouble sleeping

	1	2	3	4	5

1 is Not at all, 5 is Very Often

Have you experienced any change in your appearance because of cancer or its treatment?

YesNo
Do you feel isolated as a result of cancer or its treatment?

YesNo
How much has cancer or its treatment interfered with your personal relationships?

A lotSomewhatNot at all
How much has cancer or its treatment interfered with your work?

A lotSomewhatNot at all
How much has cancer or its treatment interfered with your sex life?

A lotSomewhatNot at all
How much do you worry about the financial burden of cancer or its treatment?

A lotSomewhatNot at all
Has cancer or its treatment ever prevented you from doing what you want to do?

YesNo
Have you made any positive changes in your life as a result of your cancer diagnosis?

YesNo
Do you consider quality of life issues when making treatment decisions?

YesNo
What year were you born?
What is your gender?

MaleFemaleTransgenderOther
What is your annual income?

Less than $15,000$15,000–$34,999$35,000–$49,999$50,000–$74,999$75,000–$99,999$100,000 or more
What is your ethnicity? (Check all that apply.)

American Indian or Alaska NativeArab or Middle EasternAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteOther
What is your ZIP code?
Enter the message as it's shown*
Should be Empty:

Quality of Life