Cancer Health_Spring_2022

Enjoy Your Life

Having cancer can make you reevaluate what’s important in your life. Please let Cancer Health know how cancer has affected the quality of your life and what actions you’ve taken to improve it.
What type(s) of cancer do you have? (Check all that apply.)

BladderBreastColorectalEndometrialKidneyLeukemiaLungLymphomaMelanomaPancreaticProstateThyroidOther
Are you currently receiving cancer treatment?

YesNo
Have you experienced any of the following conditions? (Check all that apply.)

AnxietyBrain fogConstipationDepressionFatigueMobility issuesNauseaPainTrouble sleepingNone of these
Have you experienced changes in any of the following because of cancer or its treatment? (Check all that apply.)

Personal relationshipsSex lifeWorkNone of these
Have you ever attended a cancer support group?

YesNo
Do you use any relaxation techniques?

YesNo
Have you made any changes to your exercise regimen as a result of your cancer diagnosis?

YesNo
Have you made any changes to your diet as a result of your cancer diagnosis?

YesNo
Do you frequently make time to participate in activities that you enjoy?

YesNo
Do you seek support from your family and friends?

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 current level of education?

Some high schoolHigh school graduateSome collegeBachelor’s degree or higher
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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Enjoy Your Life