Questionnaire for Patients

Questionnaire for Patients
This questionnaire is designed to explore how cancer treatment impacts sexuality, intimacy, and relationships.

Your responses will help us better understand the challenges you face and what support, resources, and education could make a meaningful difference for others healing from cancer.

Your participation is completely confidential, and your insights will help shape future support programs. Thank you!
1. Background Information:
20–2930–3940–4950–5960–6970–7980+Prefer not to say
Breast cancerProstate cancerOvarian cancerCervical cancerTesticular cancerColorectal cancerLung cancerLeukemiaLymphomaBrain cancerSkin cancer (e.g., melanoma)Head and neck cancerPrefer not to sayOther
When diagnosed
ChemotherapyRadiation therapySurgeryHormone therapyImmunotherapyTargeted therapyStem cell transplantWatchful waiting/active surveillancePalliative care/supportive carePrefer not to sayOther (Please specify)
2. Questions About Sexuality and Intimacy:
YesNo
If yes, how?
Decreased sexual desire or interest in intimacyChanges in arousal or ability to become physically stimulatedPain or discomfort during sexual activityVaginal dryness, tightness or other type of discomfortErectile changes or difficulty maintaining an erectionFatigue or lack of energy, making intimacy feel exhaustingChanges in sensation or numbness in certain areas of my bodyNausea and its impact on sexual interest turnon and pleasureWeight loss or gain that affects my body image or confidenceScarring from surgeries and/or other medical proceduresSurgical changes or loss of body parts (e.g., mastectomy, hysterectomy, prostate, testicles, etc)Hair loss (including head, eyebrows, pubic hair) affecting my self imageSkin sensitivity or discomfort from radiation or other treatmentsHormonal changes impacting mood, desire, or physical responseEmotional distress, anxiety, depression and/or fear affecting intimacyFeeling disconnected from or unfamiliar with my bodyNo noticeable changesOther
How cancer treatments (e.g., chemotherapy, radiation, surgery) affect sexual desire and functionHow hormone changes impact my libido, arousal, and sexual responseManaging physical discomfort during intimacy (e.g., pain, dryness, sensitivity)How to maintain emotional intimacy and connection with my partnerNavigating changes in my body image and self-confidence related to sexualityHow to talk to my partner about changes in my intimacy needsHow to talk to my doctor/care team about sexual health without embarrassment or discomfortHow to navigate discomfort I sense from my doctor/medical team about these topicsThe impact of medications (e.g., painkillers, antidepressants) on sexual functionUnderstanding safe ways to be sexual during and after treatmentAlternative ways to be sexual because my favorite ways of having sex are unavailable, either temporarily or permanentlyHow to navigate grief about how my body is changing in relation to sexualityOptions for fertility preservation and reproductive health concernsResources for single individuals who want to explore intimacy and sexuality post-treatmentInformation on sexual aids and tools (e.g., lubricants, vibrators, erectile support options)Finding a professional (e.g., sex therapist, intimacy coach, pelvic floor specialist) for guidanceI feel adequately informed and supported in this areaOther
YesNo
If yes, how was that for you?
If no, why not?
Are there any topics you wish your medical team had discussed/would discuss with you regarding this aspect of your health? Please share as much as you like about this.
Clear, direct information about how cancer treatments impact sexuality and intimacyGuidance on managing physical changes (e.g., pain, fatigue, vaginal dryness, erectile changes)Emotional support for body image concerns and self-esteemOpen conversations with my doctor about sexual health, especially without feeling awkward or dismissedResources or referrals to a sex therapist, intimacy coach, or counselorSupport for me about how to communicate with my partner about my experiences and how to navigate these changesSupport for my partner/spouse to understand and navigate these changes with mePeer support groups to connect with others experiencing similar challengesInformation on safe ways to explore intimacy during and after treatmentAdvice on using sexual health aids (e.g., lubricants, devices, pelvic therapy)I don’t feel I need any support in this areaOther
A guide or booklet with clear, practical advice on sexuality and intimacy during/after treatmentA private consultation with a medical professional who specializes in sexual healthOnline resources or videos explaining the impact of cancer treatment on sexuality and intimacyA support group or online community where I can talk to others with similar experiences - In personA support group or online community where I can talk to others with similar experiences - OnlineTips for communicating with my partner about changes in my body, desires, and intimacy needsAdvice on how to explore new ways of experiencing pleasure and connectionInformation on using sexual aids (e.g., lubricants, vibrators, pelvic therapy, erectile support)Suggestions for reputable sources of sexuality productsGuidance on emotional well-being, self-image, and confidence in my bodyA workshop or class designed for cancer patients and survivors on intimacy and relationshipsInformation on hormone changes and their impact on desire and sexual functionI’m not sure what would help—I need guidance on where to startOther
3. Support Needs:
YesNo
Printed guides or brochures from my medical teamOnline articles or downloadable PDFsShort educational videos explaining key topicsOne-on-one conversations with my doctor or a specialistIn-person group workshops or classes for patients and survivorsOnline group workshops or classes for patients and survivorsPrivate counseling with a sex therapist or intimacy coachAn in-person support group where I can talk with others experiencing similar challengesAn online support group where I can talk with others experiencing similar challengesAn email series with bite-sized information and tipsA mobile app or online resource hub with curated informationWebinars or live Q&A sessions with expertsPodcasts discussing intimacy, sexuality, and cancer recovery/survivorshipI’m not sureOther
4. In conclusion…
Is there anything you feel we didn’t address in the questions above that is important to you?
Please share any final thoughts, ideas, suggestions, etc.
5. Additional demographic info that helps us greatly
WomanManNon-binaryTransgenderGenderqueer/GenderfluidPrefer not to sayPrefer to self describe
SingleIn a monogamous relationship (not married)Married (monogamous)Partnered (long-term committed relationship, not married, monogamous)In a non-monogamous relationship (e.g., open relationship, swinging, solo poly)In a polyamorous relationship (multiple loving relationships with consent)SeparatedDivorcedWidowedPrefer not to sayPrefer to self-describe
OPTIONAL: Would you be open to being contacted for an interview?

This is completely optional, but we'd love to talk with you about your responses if you're open to sharing more with us. If you are, please include your contact details below and we'll reach out. 🙏🏻
Name

First NameLast Name
Email
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Phone Number
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Should be Empty:

Questionnaire for Patients

1. Background Information:

2. Questions About Sexuality and Intimacy:

3. Support Needs:

4. In conclusion…

5. Additional demographic info that helps us greatly

OPTIONAL: Would you be open to being contacted for an interview?