COPES Month 3 Survey
First name
*
May we contact you to follow up on the answers provided in this survey?
*
Yes
No
If yes, what is your preferred method of communication?
Email
Text
Phone Call
Would you recommend COPES?
*
Yes
No
In the last 3 months have you gone to the Emergency Department for symptoms related to your treatment or diagnosis?
*
Yes
No
In the last 3 months were you admitted to the hospital for reasons related to your treatment or diagnosis?
*
Yes
No
How would you rate your overall satisfaction with the COPES Program so far?
*
Please Select
Not satisfied at all
Neutral
Somewhat satisfied
Satisfied
Extremely satisfied
How helpful was the COPES program in helping you to manage the following:
Nausea/vomiting
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
Mouth issues (sores, difficulty chewing/swallowing, taste changes)
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
Appetite and weight changes
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
How helpful did you find each of the following features in COPES:
1-on-1 nutrition specialist sessions
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
24/7 messaging with experts
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
Recipe and meal planning:
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
Videos and classes
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
Goal, activity, weight and food tracking
*
Please Select
Not helpful at all
Neutral
Somewhat helpful
Helpful
Extremely helpful
How often have you had questions about the COPES program?
*
Please Select
Never
Sometimes
Usually
Always
How often have your questions about the COPES program been answered to your satisfaction?
*
Please Select
Never
Sometimes
Usually
Always
Please add any additional comments you may have about your experience with the COPES program (Optional):
Submit
Should be Empty: