Cancer Health_Fall_2019

Side Effects
All cancer treatments come with side effects, but not all side effects are the same, and everyone’s experience is different. Cancer Health wants to know what side effects you’ve experienced and how they affect your quality of life.
1) If you've been diagnosed with cancer, what type was it?
2) Have you received treatment for cancer?

YesNo (Skip to question 4.)
3) What kind of treatment have you received? (Check all that apply.)

ChemotherapyImmunotherapyRadiation therapySurgeryTargeted therapyOther
4) What physical side effects have you experienced? (Check all that apply.)

AnemiaBurnsChronic painConstipationDiarrheaDry skinFatigueHair lossInsomniaLoss of appetiteMobility issuesMouth soresNauseaNeutropeniaPeripheral neuropathySkin rashVomitingWeight gainWeight lossNoneOther
5) What mental health side effects have you experienced? (Check all that apply.)

AnxietyBrain fogDepressionMood swingsNoneOther
6) Have you been prescribed medications for side effects?

YesNo (Skip to question 8.)
7) Have the medications helped?

YesNo
8) What complementary or alternative therapies have you used to manage side effects (Check all that apply.)

AcupunctureCannabis (marijuana)Herbal remediesMassageMeditationYogaNone (Skip to question 10.)Other
9) Have these therapies helped?

YesNo
10) How much have side effects affected your quality of life?

Very muchA moderate amountA littleNot at all
11) How would you rate your physical health?

ExcellentGoodFairPoor
12) How would you rate your mental health?

ExcellentGoodFairPoor
13) What year were you born?
14) What is your gender?

MaleFemaleTransgenderOther
15) What is your ethnicity? (Check all that apply.)

American Indian or Alaska NativeArab or Middle EasternAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteOther
16) What is your zip code?
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Side Effects