Questionnaire for Post-Treatment Patients

Questionnaire for Survivors
This questionnaire seeks to understand the lasting effects of cancer on intimacy, sexuality, and relationships. Survivorship brings its own set of challenges, and your experiences can help identify gaps in support and resources, ensuring future survivors have access to the guidance they need.

Your responses are anonymous, confidential, and will be used to shape meaningful support and programs for those navigating intimacy after cancer. Thank you!
1. Background Information:
Age
Type of Cancer: (Please select all that apply)

Other
Time since completion of cancer treatment:
2. Questions About Sexuality and Intimacy Post-Treatment:
Have your feelings about your body and sexuality changed since your treatment ended?
If yes, how?
Have you experienced/did you experience any ongoing physical or emotional challenges that affect your intimacy or sexual activity? (Select all that apply)

Other
Did you feel adequately supported to address these challenges?
Did you receive information or guidance about sexuality and intimacy during your treatment?
If not, would it have been helpful? Specifically why?
What, specifically, was or would have been helpful? (Select all that apply)

Other (please specify)
3. Support Needs:
What kind of support, if any, would you find beneficial now? (Select all that apply)

Other (please specify)
Optional: Is there a specific topic you think should be prioritized in support programs for cancer survivors regarding intimacy and sexuality?
4. Reflections
Looking back, what advice would you give to someone currently undergoing cancer treatment about addressing sexuality and intimacy?
What information do you think medical staff should prioritize when discussing intimacy with patients?
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 (but optional) demographic info that helps us greatly
Optional (but helpful): Gender (Select all that apply)

Prefer to self describe
Optional (but helpful): What is your relationship status? (Select all that apply)

Prefer 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 Survivors

1. Background Information:

2. Questions About Sexuality and Intimacy Post-Treatment:

3. Support Needs:

4. Reflections

5. Additional (but optional) demographic info that helps us greatly

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