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West Virginia Resource Connector
Email
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Your answers to the following questions will help us better serve you and other cancer patients receiving care in West Virginia.
Zip Code
*
Race/Ethnicity
*
White
Hispanic
African Amercan/Black
Native American or Alaskan Native
Asian or Pacific Islander
Other
Gender
*
Age
*
Do you receive Medicaid?
*
Please Select
Yes
No
Unsure
I am a...
*
Newly Diagnosed
Undergoing Treatment
Finished with Treatment But Being Monitored
In Remission
Cancer Free
None of these
Other
Unique ID (NOTE: if this is your first time filling out an assessment, do not change)
*
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Please circle the number that best describes (overall) how much distress you have been experiencing in the past week, including today. (Low to high)
No Distress
0
1
2
3
4
5
6
7
8
9
High Distress
10
0 is No Distress, 10 is High Distress
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Information
This is one of my top interests
I want more information about this
[My cancer diagnosis]
[The short-term side effects of treatment]
[The long-term side effects of treatment]
[What will happen when treatment finishes]
[My disease status]
[My test results]
[What to do if I have side effects from my treatment]
[How my genetics may or may not have impacted my diagnosis and treatment]
Cancer Care Team
This is one of my top interests
I want more information about this
[Respecting me as an individual, not just a cancer patient or survivor]
[Offering to talk to me in private, without my family or friends]
[Explaining what they were doing in a way I can understand]
[Encouraging me to ask questions]
[Engaging me in decision-making about my treatment and respecting my decisions]
[Asking me about my treatment concerns]
Physical Health
This is one of my top interests
I want more information about this
[Managing pain]
[Managing my medications]
[Managing physical side effects of treatment]
[Managing feeling tired/fatigued]
[Managing loss of walking ability]
Emotional Health
This is one of my top interests
I want more information about this
[Feeling anxious or scared]
[Feeling depressed]
[Having what I need to cope with my diagnosis]
[Worrying about my cancer spreading]
[Worrying about my cancer returning or getting another type of cancer]
[Worrying about how my family is coping]
[Coping with changes in my dating or romantic life]
[Coping with changes in my relationships with my family members]
[Coping with changes in my relationships with friends]
[Feeling a loss of independence]
[Coping with changes in my physical ability]
[Coping with changes in my appearance]
[Coping with not being able to do the same things as other people my age]
[Managing the emotional side effects of treatment]
[Being able to make plans or think about the future]
Sexual & Reproductive Health
This is one of my top interests
I want more information about this
[My risk of infertility and my fertility preservation options]
[Treating infertility and other options for having children in the future]
[Sexuality and intimacy during cancer treatment]
[Sexual side effects of my treatment]
[The effects of treatment on long-term hormone changes]
Health Behaviors & Wellness
This is one of my top interests
I want more information about this
[Nutrition]
[Exercise or physical activity]
[Getting enough or better-quality sleep]
[Smoking or vaping during cancer treatment]
[Drug or alcohol use during cancer treatment]
[Spiritual support or resources]
[Alternative therapies]
Work & Education
This is one of my top interests
I want more information about this
[Keeping up with my peers in school]
[Help with transitioning back to school]
[Managing my school life during or after my cancer treatment]
[Figuring out what activities or clubs to get involved in]
[Figuring out what classes to take]
[Figuring out how to plan for my desired career]
[Figuring out what I want to do for a career]
[Getting experience in a career field I am interested in]
[Understanding different jobs I can have in my intended career field]
[Deciding if I should go to a trade school or college]
[Figuring out what to major and/or minor in]
[Figuring out what higher education programs to apply for (e.g. trade, college, graduate school)]
[Getting scholarships]
[Finding opportunities to network]
[Learning how to create a resume]
[Learning how to find and apply for internships]
[Preparing for job interviews]
[Managing my work life during or after my cancer treatment]
Peer Support & Programming
This is one of my top interests
I want more information about this
[Being able to spend time with people my own age]
[Being able to talk to people my own age who have been through a similar cancer treatment experience]
[Participating in social activities]
Finance & Everyday Needs
This is one of my top interests
I want more information about this
[Paying my bills]
[Scholarship or loan repayment options]
[My health insurance]
[Getting to and from my cancer care appointments]
[Having childcare during my cancer care appointments]
[Having stable housing]
[Having access to food]
Can we follow up with you in the future via email to ask for your feedback on this tool?
Yes
No
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