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 day Several times a week Once a week I don’t exercise regularly.
Do you maintain a healthy and balanced diet?

Yes No
Do you get enough sleep each night?

Yes No
Do you smoke cigarettes?

Yes No
How often do you drink alcohol?

Frequently Occasionally Rarely I don’t drink alcohol.
Do you regularly take time to unwind and relax?

Yes No
How often do you feel stressed?

Frequently Occasionally Rarely
Do you find healthy ways to manage your stress?

Yes No
Do you have a good support network?

Yes No
Do you participate in any support groups?

Yes No
Do you get any wellness support from your health care team?

Yes No
Do you regularly find ways to stimulate and challenge yourself mentally?

Yes No
Do you have a faith or spiritual practice that is important to you?

Yes No
What year were you born?
What is your gender?

Male Female Transgender
What is your current level of education?

Some high school High school graduate Some college Bachelor’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 Native Arab/Middle Eastern Asian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White
What is your ZIP code?
Please verify that you are human *
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Your Wellness Plan