Jewish Family Services Oncology Snack Program
Your answers to these questions are private, confidential, protected health information and will not be shared in any sort of identifiable way with any additional parties outside of JFS.
Name
*
First Name
Last Name
Delivery Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you able to accept a Friday delivery?
*
Yes
No
How did you learn about this program? (i.e. medical provider, online, faith-based community, etc.)
*
What is your current cancer diagnosis?
Would you like to receive a 6 pack of liquid nutrition with your weekly delivery?
*
Yes
No
Which of the following apply to you? (Select all that apply)
*
Peanut allergy
Tree nut allergy (almonds, walnuts, etc.)
Dairy-free / lactose intolerant
Gluten free
Diabetic-friendly (low-sugar)
Vegetarian / vegan
None of the above
Other (see next question)
If you selected "other" above, please add restriction below:
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Pre-Survey
Thank you for participating in our Healthy Snack Program. This is a grant-funded pilot program. Completion of this brief pre-survey is required (and a similar brief post-survey at the end of your participation) will help us continue to improve our support for program enrollees and may help determine if the program continues past the pilot period. Thank you in advance for answering these questions.
During your breast cancer treatment, how often do you experience the following?
*
Rows
Never
Rarely
Sometimes
Always
Prefer not to answer
Fatigue/Low Energy
Nausea/Apetite Loss
Taste Alterations
Please rate your agreement with the following statements: (Select one per row)
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Prefer not to answer
"
I find it easy to find or prepare healthy snacks on days I have treatment."
"I frequently opt for convenient or processed snacks even if they are less healthy."
"Financial or physical barriers make it difficult for me to access nutrient-dense foods."
"As I navigate treatment, I would prefer to spend my energy on other activities more than preparing healthy snacks."
How confident do you feel about choosing snacks that support your body's healing and energy needs right now?
*
Please Select
Not at all confident
Slightly confident
Moderately confident
Very confident
Prefer not to answer
Choose one option
Do you find yourself skipping snacks or meals because you are traveling to or waiting at appointments?
*
Please Select
Yes, frequently
Sometimes
Rarely or never
Prefer not to say
Choose one option
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THANK YOU!
Our staff will reach out to you in 2-3 business days regarding the program. If you have any questions, please email christinet@jfsannarbor.org.
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