Cancer Health_Spring_2022

Your Wellness Plan

Whether you are in treatment or in recovery or are a long-term survivor, it’s a good idea to talk with your doctor about how to take care of your physical, emotional, social and spiritual needs. Take our survey and let Cancer Health know how you promote wellness in your life.
How often do you exercise?

Every daySeveral times a weekOnce a weekI don’t exercise regularly.
Do you maintain a healthy and balanced diet?

YesNo
Do you get enough sleep each night?

YesNo
Do you smoke cigarettes?

YesNo
How often do you drink alcohol?

FrequentlyOccasionallyRarelyI don’t drink alcohol.
Do you regularly take time to unwind and relax?

YesNo
How often do you feel stressed?

FrequentlyOccasionallyRarely
Do you find healthy ways to manage your stress?

YesNo
Do you have a good support network?

YesNo
Do you participate in any support groups?

YesNo
Do you get any wellness support from your health care team?

YesNo
Do you regularly find ways to stimulate and challenge yourself mentally?

YesNo
Do you have a faith or spiritual practice that is important to you?

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

MaleFemaleTransgenderOther
What is your current level of education?

Some high schoolHigh school graduateSome collegeBachelor’s degree or higher
What is your annual household 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/Alaska NativeArab/Middle EasternAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/Pacific IslanderWhiteOther
What is your ZIP code?
Please verify that you are human*
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Your Wellness Plan