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 programs for those navigating intimacy after cancer. Thank you!
1. Background Information:
Age*

20–2930–3940–4950–5960–6970–7980+Prefer not to say
Type of Cancer: (Please select all that apply)*

Breast cancerProstate cancerOvarian cancerCervical cancerTesticular cancerColorectal cancerLung cancerLeukemiaLymphomaBrain cancerSkin cancer (e.g., melanoma)Head and neck cancerPrefer not to sayOther
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?*

Yes, positivelyYes, negativelyNo
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)*

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
Did you feel adequately supported to address these challenges?*

YesNo
Did you receive information or guidance about sexuality and intimacy during your treatment?*

YesNo
If not, would it have been helpful? Specifically why?
What, specifically, was or would have been helpful? (Select all that apply)*

A dedicated conversation with my doctor or care team about intimacy and sexual healthWritten materials (e.g., brochures, handouts, guides) on sexuality and intimacy during and after treatmentOnline resources or educational videos explaining the impact of treatment on sexual healthA referral to a specialist (e.g., sex therapist, intimacy coach, pelvic health therapist)Support groups or peer discussions with others experiencing similar challenges in personSupport groups or peer discussions with others experiencing similar challenges onlineGuidance on how to talk to my partner about changes in intimacy and sexualityPractical solutions for managing physical side effects (e.g., vaginal dryness, erectile changes, fatigue)Information on sexual aids and resources (e.g., lubricants, vibrators, positioning techniques)Suggestions for reputable sources of sexuality productsEmotional support to help with body image, self-esteem, and confidenceClearer expectations on how long changes in sexuality or intimacy might lastMore open, non-judgmental conversations with my care team about these topicsI did receive helpful information and felt supportedI’m not sure—I didn’t know I could ask about thisOther (please specify)
3. Support Needs:
What kind of support, if any, would you find beneficial now? (Select all that apply)*

One-on-one therapy or counseling focused on intimacy and sexualityA support group to connect with others experiencing similar challenges in personA support group to connect with others experiencing similar challenges onlineEducational materials (e.g., guides, articles, books) on sexuality, intimacy, and cancer recoveryOnline workshops or webinars with experts in sexual health and intimacyConversations with my medical team about my concerns and available optionsResources specifically for my partner to help them understand and support mePractical guidance on using sexual aids, devices, and techniques to adapt to changesSuggestions for reputable sources of sexuality productsMore information about the long-term effects of my treatment on sexuality and relationshipsA space to ask questions privately, such as a Q&A with a specialistI feel like I have enough support in this areaOther (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 during their healing journey?*
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)

WomanManNon-binaryTransgenderPrefer not to sayPrefer to self describe
Optional (but helpful): What is your relationship status? (Select all that apply)

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
example@example.com
Phone Number
Please enter a valid phone number.
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?