• 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 experiencing cancer. 

    Your participation is completely confidential, and your insights will help shape future support programs. Thank you!

  • 1. Background Information:

  • Age*
  • Type of Cancer: (Select all that apply)*
  • Treatment(s) you've done/are doig: (Select all that apply)*

  • 2. Questions About Sexuality and Intimacy:

  • Have you noticed any way(s) that your cancer treatments have impacted your interest in or ability to engage in sexual activity?*
  • What changes have you noticed in your body that affect how you feel about your sexuality or intimacy? (Select all that apply)
  • Are there specific areas where you feel uninformed or unsupported about the effects of cancer on your sexuality or intimacy? (Select all that apply)*
  • Have you talked with any members of your medical team about these issues?*
  • What support from your care team would help with these challenges? (Select as many as you like)*
  • Optional (but extremely helpful): What types of resources or information would help you feel more confident in addressing your intimacy and sexuality concerns?

  • 3. Support Needs:

  • Would you be interested in having access to workshops or classes (online, on-demand, in-person) to learn about how to navigate and support sexuality and intimacy during cancer?*
  • Optional (but extremely helpful): If yes, how would you prefer to receive this information?

  • 4. In conclusion…

  • 5. Additional demographic info that helps us greatly

  • Optional (but helpful): Gender (Select all that apply)
  • Optional (but helpful): What is your relationship status? (Select all that apply)

  • 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. 🙏🏻
  • Format: (000) 000-0000.
  • Should be Empty: